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 Referral Form

• Referring Physicians Name*
• Referring Physicians Address*
  Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Fax Number*
• Patient Date of Birth*
• Patient First Name*
• Patient Last Name*
• 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
• Physician Preference*
  • Ryan P. Conley, D.O.
  • Mary Anne Ahluwalia, D.O.
  • Neel M. Kumar, M.D.
  • Benjamin Stephens, M.D.
  • Valerie Lobodiak, M.D.
  • No Preference / Not Sure
• Preferred Clinic Location for Appointment
  • Tulsa - Main
  • Tulsa - Satellite (T2)
  • Tulsa - Aesthetics & Laser Center
  • Tulsa - Brookside
  • Bartlesville
  • Grove
  • McAlester
  • Muskogee
• 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.