PATIENT REFERRAL FORM

Refer a Patient with Ease

Securely Submit Patient Information to Expedite Care

Thank you for partnering with us in delivering exceptional care. Please use the forms below to quickly and securely refer your patients. Our team will review the information promptly and follow up to ensure a smooth transition of care. If you have any questions during the referral process, don't hesitate to reach out by emailing us at eyeconoptometry@eyeconsee.com or calling (818) 345-2010.

Myopia Management / Ortho-K

Specialty Contact Lens / Keratoconus

ORTHO-K MYOPIA CONTROL
CO-MANAGEMENT/ REFERRAL

Please call 818.345.2010 or visit our website eyeconsee.com to schedule
your myopia control consultation with Dr. Ha, Dr. Zadoorian, or Dr. Nguyen.

Patient Name

DOB

Parent's Name

Exam Date

Parent's Preferred Contact Method:

Phone

The patient and/or patient's parents have had their questions answered regarding the consequences of treating versus not treating the patient's myopia, especially the additional risks to eye health associated with increasing myopia.

Yes

The patient has been myopic for approximately ______ years.

Myopic Parents:

Mother

Father

Both

Neither

VA sc : OD 20/ ____

OS : 20/______

Previous Rx: OD : _______________________________ 20/____________

OS : _______________________________ 20/____________

Current Sub Rx: OD : _______________________________ 20/____________

OS : _______________________________ 20/____________

Referring Doctor:

Doctor's Email:

Submit

SPECIALTY CONTACT LENS/KERATOCONUS REFERRAL

Please call 818.345.2010 or visit our website eyeconsee.com to schedule
your specialty contact lens consultation exam with Dr. Ha, Dr. Zadoorian or Dr. Nguyen