Patient Referral Form
Referring Doctor
Doctor Name
Address
City
State
Zip
Phone
Fax
Email
Patient Information
Patient Name
Date of Birth
Home Phone
Cell Phone
Work Phone
Email
Please See Patient Within
Days
Weeks
Months
Please call if the patient should be seen urgently
KC Eye Clinic Physician
Fred Bodker, MD
Johann Ohly, MD
Chris Ketcherside, MD
Kristin Biggerstaff, MD
Megan Haghnegahdar, MD
First Available
Patient Requires
Cataract Evaluation
(please send notes from latest visit)
YAG Capsulotomy Evaluation
(please send notes from latest visit)
Glaucoma Evaluation
Cornea Evaluation for
Fuchs Dystrophy
Keratoconus
EBMD
Other Cornea
Oculofacial Plastic Evaluation for
Eyelid
Lacrimal System
Facial/Eye Lesion
Other Oculofacial
Diagnosis and Notes
Glaucoma Referrals
For the best evaluation of your patient’s glaucoma history, please provide:
Chart Notes from their last 3-4 Visits
All available Visual Field testing, OCT Imaging and IOP History
Tonometry
OD
OS
Date
Tmax
OD
OS
Date
Please note if Visual Field / OCT testing has not been done or is not available:
Imaging & Testing will be sent
Imaging & Testing is not available
Cornea Referrals
For the best evaluation of your patient’s cornea history, please provide Chart Notes from their last 2-3 Visits
Lid Lacrimal or Lesion Referrals
Please provide Chart Notes and a specific functional complaint from the patient
Record Uploads
For your convenience, we have a HIPAA-compliant file upload utility that’s faster and more reliable than fax. Please create PDFs (one or more) of requested records and upload here.
To select multiple files, hold down the CTRL or SHIFT key while selecting.