APPOINTMENT CARD

APPOINTMENT CARD

After scheduling an appointment in our office, complete this appointment card for your patient to inform them of their appointment date and time at our office, instructions for their appointment, and directions to our office.

URGENT REFERRAL FORM

PHONE CALL SCREENING INFORMATION FOR URGENT REFERRALS 

When referring a patient with an urgent diagnosis such as a retinal detachment or retinal tear, we require a phone call to 701-293-9829, option 2 for triage and scheduling.  We ask that you review our Phone Call Screening Information for Urgent Referrals form and have all the necessary information available when calling to make the referral.  If the patient needs to be seen within 24 hours of the referral phone call, the patient must be present in your office when the referral call is made.

ROUTINE (NON-URGENT) REFERRAL FORM

ROUTINE REFERRAL FORM

To make a routine referral, please complete the Routine Referral Form.  Fax the completed form and required information below to our referral fax number at 701-205-3460 (please note, our referral fax number is different from our main fax number).  Our clinical specialists will contact your patient within four business days to schedule an appointment.  Once we contact your patient, we will fax a referral update form back to your office with appointment information.

Required Information for routine referrals:

  • Patient demographics including patient name, DOB, address, phone number, medical insurance company, and medical insurance identification numbers.

  • Referral office note.