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Make a Referral

Fill out the form below, or download it here. (Referral Service Form)

Date of Referral: (required)
Patient Name: (required)
Date of Birth: (required)
Patient Address:
City: State: Zip Code:
Patient Phone #: (required)
Patient Additional Phone #:
Patient Email Address:
Referred By: (required)
Address of Referring Provider: (required)
City: (required) State: (required) Zip Code: (required)
Phone: (required) Fax:
E-mail Address:

Do you dispense eyeglasses at this location? Yes No

I would like my patient to continue care at SUNY for the referred issue. Patient is
to return to me for comprehensive care.

Referred to (check one) (required)

Imaging Center Only

Consultation

Consultation & Treatment

URGENT(required)

Yes

No

Correspondence (check one) (required)

Please Call

Mail report

Fax report

Imaging Center / Structural Testing:

HRT3          GDx VCC
Stratus OCT 3          Spectral Domain OCT
Optical Biometry (IOL Master)          Corneal Topography (Orbscan)
Pachymetry         Ultrasound Biomicroscopy
A and B Scan Ultrasonography          Fluorescein Angiography (Diagnosis Needed)
Digital Photography

Functional Testing:

Standard Automated Perimetry

Frequency Doubling Technology Perimetry (FDT)

VEP

ERG

Specialty Care

Cataract          Cornea
Glaucoma          Retina
Neuro-ocular          Oculoplastics
Outpatient Surgery          Refractive Surgery (Laser Eye Institute)
Vision Therapy          Head Trauma/Acquired Brain Injury
Learning Disabilities          Pediatrics (5 to 9 years of age)
Infant Vision (birth to 4 years of age)          Children with Special Needs (up to 18 years of age)
Adults with Disabilities          Specialty Contact Lenses
Low Vision Rehabilitation Primary Care
Dry Eye Hereditary Retinal and Optic Nerve Disease
Pediatric Ocular Disease
Diagnoses: Patient's most recent refraction: OD
Patient's most recent refraction: OS
Reason(s) for Referral/Pertinent Information: (required)

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