Please complete the form below then sign and click “Submit.” 

***You can now attach medical records to the online form!  See “Patient File Upload” at the bottom of the form.***

Physician Appointment Request

• Referring Physicians Name*
• Referring Physicians Address*
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Referring Physician Office Phone*
• Referring Physician Office Fax*
• Patient Date of Birth*
• Patient First Name*
• Patient Last Name*
• Patient Address*
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Patient Phone*
• Patient Email
• Patient Gender*
  • Male
  • Female
• Is the Patient Deaf/Hearing Impaired?*
  • Yes
  • No
• Will the Patient Be Bringing Their Own Interpreter?*
  • Yes
  • No
• What is the best way for us to contact your patient?**
  • Phone
  • Text
  • Email
• What is Their Preferred Language?*
  • English
  • Spanish
  • American Sign Language
• Reason for Visit*
  • Cataract
  • LASIK
  • Glaucoma
  • Diabetic
  • Blepharoplasty/Oculoplastics
• **Please be advised that cataract removal surgery must be scheduled within 90 days of evaluation.**
• Physician Preference*
  • Ryan P. Conley, D.O.
  • Mary Anne Ahluwalia, D.O.
  • Jordan Guffey, M.D.
  • Neel M. Kumar, M.D.
  • Valerie Lobodiak, M.D.
  • Michael Mequio, M.D.
  • Peter Wojcik, M.D.
  • No Preference
• Preferred Clinic Location for Appointment
  • Tulsa - Main
  • Tulsa - Satellite (T2)
  • Tulsa - Aesthetics & Laser Center
  • Tulsa - Brookside
  • Bartlesville
  • Bentonville, AR
  • Claremore
  • Fayetteville, AR
  • Grove
  • McAlester
  • Muskogee
  • Pryor
• Comments
• Patient File Upload
  Drop files here or Select files

  Max. file size: 300 MB.
• Name
  This field is for validation purposes and should be left unchanged.