Fill out the form below, or download it here. (Referral Service Form)
Do you dispense eyeglasses at this location?* (required)
Important: Please sent a copy of the most recent eye exam along with this form.
I would like my patient to continue care at SUNY for the referred issue. Patient is to return to me for comprehensive care.I would like to transfer care of this patient to SUNY.
Imaging Center Only (Diagnosis Needed)ConsultationConsultation & Treatment
If Imaging Center Only (check one)
With InterpretationWithout Interpretation
ONH/NFL ImagingCorneal TopographyFluorescein Angiography (Diagnosis Needed)Macular/Retinal ImagingPachymetryDigital PhotographyUltrasound BiomicroscopyVisual Field TestVEPOptical Biometry (IOL Master)A and B Scan UltrasonographyERG/EOG
Do Not Check Off If Imaging Only Referral
CataractCorneaContact LensesMyopia Control (Please submit copy of complete eye exam & DFE results)Children with Special Needs (up to 18 years of age)Adults with DisabilitiesLearning DisabilitiesLow Vision RehabilitationOculoplasticsDry EyeHereditary Retinal and Optic Nerve DiseaseProsthetic FitRetinaSports VisionPrimary Care/Comprehensive Eye Exam (14 years of age & older)Color Vision TestInfant Vision (birth to 4 years of age)Pediatrics (5 to 13 years of age)Pediatric Ocular Disease (13 years of age and under)Vision Therapy (Please submit copy of complete eye exam & DFE results)Head Trauma/ Acquired Brain InjuryGlaucomaNeuro-ocular
Patient's most recent refraction