Refer a Patient

Referring Doctor's Name:

Referring Doctor's Phone Number:

Referring Doctor's Fax:

Patient's Name:

Patient's Date of Birth:

Patient's Phone Number:

Patient's Medical Insurance (if known):

Preferred Office:

Reason for Referral:

Please Describe Reason:

Attach Notes (optional):

Please do not refer emergencies on this form.

I am an optometrist and would like to comanage this patient for cataract surgery. I have reviewed comanagement with the patient and the patient agrees to proceed. I am set up on Cofi.

ASK US A QUESTION

Name*

Email*

Phone*

I am contacting you about:*

Comments*

Quick links

Home Our Physicians Patient Resources Contact Us Testimonials Sitemap

Cataract Solutions Laser Vision Correction Finding a Cataract Surgeon General Eyecare Optical Boutique Cosmetic Center Accessibility Statement

Huntington Beach

18582 Main Street, Huntington Beach, CA 92648 714-965-9696 fax: 714-965-9797

Irvine

4870 Barranca Pkwy Ste 210 Irvine, CA 92604 949-978-9696 fax: 949-978-9797

Long Beach

2650 Elm Avenue, Suite 108 Long Beach, CA. 90806 562-427-5409 fax: 562-426-6321

Newport Beach

520 Superior Ave. Ste 295 Newport Beach, CA 92663 949-969-9696 fax: 949-969-9797

Get connected with us on

4.9 stars based on 578 Reviews

"For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ( $10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public."

Google Rating

4.8

Based on 745 reviews