OD Electronic Referral Consult Form

Electronic Consult Request Form

Thank you for partnering with NVISION to provide the best care for your patients. Submit the completed form and we will reach out to your patient as soon as possible.

Step 1 of 5

Patient Preferences

Preferred Treatment *

Available Locations *

Preferred Surgeon

Area Manager *

Reason for Referral / Comments

Step 2 of 5

Patient Info

First Name *

Last Name *

Street

City

State/Province

Zip Code

Email *

Birthday

Phone *

Mobile Phone

Work Phone

Preferred Contact

Step 3 of 5

Manifest Refraction or Current Spectacle Rx

20/

ADD

Ocular Hx

Contact Lens History

Number of Years Worn

Monovision

Near Target

Step 4 of 5

Patient Insurance Info

Primary Insurance Carrier

Primary Policy Number

Primary Group Number

Secondary Insurance Carrier

Secondary Policy Numbner

Seconday Group Number

Step 5 of 5

OD Info

Referring OD Name *

Referring OD Email (for submission confirmation email) *

OD Phone (from referring location)

OD Fax (from referring location)

Practice Owner (if different than above)

Practice Address *

Co-Manage Desire