Refer A Patient - Gailey Eye Clinic

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Patient Name*

First Last

Patient Phone*

Patient DOB*

Preferred Provider/Specialty*

Brief Description of Referral*

Referring Provider Name*

First Last

Referring Provider Practice Name*

Referring Provider City, State*

Referring Provider Phone*

Referring Provider Email*

Referring Provider Fax

Upload Clinical Notes, Insurance Cards, Testing/Images, etc.*

Drop files here or

Max. file size: 50 MB.

Is this your first time referring to Gailey Eye Clinic?*

Yes

Cataract Surgery Referrals Only*

If your patient is a contact lens wearer, please instruct patient to discontinue wearing their contact lenses (if possible) prior to their surgical consulation appointment with a Gailey Eye Clinic surgeon. Does your patient wear contact lenses?

Yes

Gailey Eye Clinic Contact Lens Protocol

Soft Contacts - Patient should be out of CL for 1 week prior to exam and should wear glasses during this time.

Soft Toric Contacts - Patient should be out of CL for 2 weeks prior to exam and should wear glasses during this time.

Gas Permeable/Hard Contacts - Patient should be out of GP/Hard CL for 3 weeks prior to exam and should wear glasses during this time.

Comments

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