Internet Explorer is no longer supported and you may experience issues submitting a referral. Please use Chrome, Edge or Firefox.
Request for Consultation
You will have the opportunity to save this information in PDF format following submission.
*
indicates a required field
Referring Provider Information
Remember my information
Referring Doctor
*
Referring Practice Name
*
Email
*
Phone
*
Fax
*
Address
*
City
*
State/Zip
*
Patient Information
First and Last Name
*
DOB
*
Phone Number
*
Address
*
City
*
State/Zip
*
Gender
*
Height
Weight
Interpreter Needed?
*
Yes
No
Primary Insurance Provider
Insurance ID Number
Insurance Group Number
Secondary Insurance Provider
Insurance ID Number
Insurance Group Number
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
Select a doctor
*
Select the patient’s preferred location(s)
*
Location Info
Bloomington
Minnetonka
Woodbury
Blaine
Crosstown
Any
What type of consultation is needed?
*
Cataract Consult
Please choose at leaset one option
Light Adjustable Lens
Multifocal Lens
Extended Depth of Focus Lens
Toric Lens
Basic Lens
Cornea Consult
Dry Eye Eval
Refractive
Research
General
Glaucoma Consult (please attach any/all historical Glaucoma testing)
Oculoplastic
Please choose at leaset one option
Lesion
Functional
PCO Eval
Testing Only
Immersion
IOL Master
GDX (Scanning Laser Polarimetry)
HRT (Confocal Scanning Laser Ophthalmoscopy)
Macular
RNFL
Humphrey
Pentacam
Sita Fast Humphrey 24-2
Standard Humphrey 24-2
Goldman Visual Field (Lids Only)
Other
ICD-10/Diagnosis Codes for Tests
The Vision Project
Other
URGENT referral
(ex: pain, severe redness, flashes of light/new floaters, etc.)
Additional conditions to be evaluated or notes to the scheduling team
Please attach most recent chart note(s) & describe the conditions to be evaluated and list all patient allergies
Choose file
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.
If surgery is recommended, I’d like to co-manage the patient’s post op care if the surgeon feels medically appropriate.
If surgery is recommended, I’d prefer Minnesota Eye Consultants to assume the patient’s post op care and will resume the general care of the patient after the post op period.
If surgery is recommended, I’d like patient to be considered for Imprimis drops
Click here to sign up for our monthly referral newsletter!
Submit
Loading...
File size too large
Incompatible file type
Surgeon Location Information
×