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Request for Consultation

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Referring Provider Information

Patient Information
Depending on the patient’s age, medical history, care needs and BMI, the patient may be scheduled at an affiliated hospital instead of our Ambulatory Surgery Center (ASC).

Appointment Request

Doctor/Specialty

What type of consultation is needed? *
Please choose at leaset one option
Please choose at leaset one option
ICD-10/Diagnosis Codes for Tests

Please attach most recent chart note(s) & describe the conditions to be evaluated and list all patient allergies

File limit: 15mb and 10 files max

Attached Files

Co-Management Preferences

Following our evaluation, we will communicate any findings and/or treatment recommendations. If surgery is necessary please indicate below if you'd like to co-manage. Regardless, all patients will be sent back to the referring provider to resume general eye care as appropriate.