OD/MD PortalSecure uploadReferral CRM

Referral Intake

Submit patient referrals, clinical summary, and diagnostic files into the Visionary Eye Surgery referral queue.

Optometrist and submitter identity details

Referring optometrist

Enter the clinician responsible for this referral.

Referring Optometrist NPI

Referring Optometrist Name *

Practice

Credentials *

Referring Optometrist Email *

Provider Phone

Provider Fax

Patient demographics for referral matching

First Name *

Last Name *

Date of Birth *

Phone

Referral type, priority, and clinical notes

Consultation Type *

Appointment Type *

Urgency

Preferred Physician

Reason for Referral *

Allergies

Refraction, acuity, and pressure

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OD
OS

Post-operative care preference

I wish to co-manage this patient's post-operative care

Post-op visits return to your office per the co-management schedule; Day 1 is seen at VES unless arranged otherwise.

Records, topography, OCT, and supporting documents

Records / Chart NotesTopographyOCTOther Files

Encrypted transmission. No patient data is sent by email.

Want this form to remember you?

Create an account to save provider details, reuse them on future referrals, track case status, and receive reports.