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Ophthalmology Referral

Please use the form below to submit your referral or download the Ophthalmology Referral form to print and email to our Practice Administrator or fax to (512) 427-1210.

Patient Name Age

Patient Email

Patient Phone

Patient History

Patient Diagnosis

Type of Consultation or Management
CorneaKeratoconusLASIK / PRK Eligibility EvalCataract / Cloudy LensDry EyesPterygiumForeign BodyDiabetic EvaluationPlaquenil / High Risk Meds Eval (Lupus)Plaquenil / High Risk Meds Eval (Rheumatoid Arthritis)Glaucoma / Glaucoma SuspectOcular Headache / MigraineExternal: Stye, Lesion, EyelashOther

Diagnostic
A-Scan / Zeiss IOL Master® OD OS OUOPD Scan / Pentacam® HR Corneal Map OD OS OUHumphrey® Visual Fields / FDTOptomap® Fundus PhotosPascal® Tonometry / Serial TonometryCirrus™ HD Ocular Coherence TomographyCorneal PachymetryAnterior Segment PhotographyTearLab™ Osmolarity TestingOther

Referring Doctor’s Name

Phone Number Doctor's Line

Address City/State/Zip