Print this form and fax to (702) 605-5055

DESERT RETINA — PATIENT REFERRAL FORM

Phone: (702) 702-2002 | Fax: (702) 605-5055 | Email: info@dretina.com | dretina.com

George Par, MD — Board-Certified Vitreoretinal Surgeon

URGENCY (circle one):

🟢 Routine (1–2 weeks)🟡 Urgent (this week)🔴 Emergency (same day — also call 702-702-2002)

REFERRING DOCTOR

Doctor Name:

Practice Name:

Phone:

Fax:

Email:

NPI:

Preferred Contact Method:

PATIENT INFORMATION

Patient First Name:

Patient Last Name:

Date of Birth:

Phone:

Insurance Company:

Member / Policy ID:

Secondary Insurance:

Authorization / Ref #:

REFERRAL DETAILS

Reason for Referral (check all that apply):

AMD (Wet)AMD (Dry)Diabetic RetinopathyDiabetic Macular EdemaRetinal DetachmentRetinal Vein OcclusionMacular HoleEpiretinal MembraneFloaters / PVDVitreous HemorrhageRetinal TearUveitis / VitritisPlaquenil ScreeningCentral SerousOcular TumorOther (specify below)

Visual Acuity (OD / OS):

IOP (OD / OS):

Clinical Notes / History:

Images / Records Attached (check all that apply):

OCT ImagesFundus PhotosFluorescein AngiographyVisual FieldB-scan UltrasoundClinical NotesSurgical RecordsOther

Fax completed form to (702) 605-5055 or email to info@dretina.com

Online referral: dretina.com/referrals | Urgent: call (702) 702-2002

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