Patient Referral Form Direct Referral Line for Lafayette Eye Associates: (720) 713-3175 Referring Physician* Sherrie Nunn, OD David Himel, OD Physician Phone*Physician FaxReferring Physician Contact Person* First Last Email* Patient Name* First Last Date of Birth* MM slash DD slash YYYY Patient Phone*Patient needs to be seen* EMERGENTLY/Today Within 24 hours Within 2-3 days Within 1 week Within 4 weeks Next available For patients needing to be seen emergently or today, please call (303) 772-3300 in lieu of this form)Insurance CarrierInsurance cards if available Drop files here or Select files Max. file size: 300 MB.Referral for:Cataract Select All Joel Meyers, MD Aimee Verner, MD Micah Rothstein, MD Anjali Sheth, MD Mansi Parikh, MD Retina Select All William Benedict, MD Elisha Tilton, MD Justin Kanoff, MD Matthew Manry, MD Glaucoma Select All Micah Rothstein, MD Anjali Sheth, MD Mansi Parikh, MD Cornea / Refractive Surgery Aimee Verner, MD Oculoplastics Joel S. Meyers, MD Please provide a brief description of the patient’s problem and the clinical question to be answered by our physicians in the box below.*Last chart note Drop files here or Select files Max. file size: 300 MB.Last chart note Drop files here or Select files Max. file size: 300 MB.Last chart note Drop files here or Select files Max. file size: 300 MB. Consider treatment as appropriate. I look forward to receiving your opinion and advice regarding the care of this patient, and will resume general care following your consultation. I prefer to co-manage this patient [Cataract or LASIK] I request that you refer to another specialist if additional problems/conditions are discovered upon evaluation. NameThis field is for validation purposes and should be left unchanged.
