P: (303) 772-3300 | F: (303) 682-3380 | M-F 7:30am – 5:30pm

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Patient Referral Form

Direct Referral Line for Front Range Eye Health Center: 720-684-4332

Existing Patient Inquiry

New Patient Inquiry

BOULDER

3000 Center Green Drive
Suite 250
Boulder, CO 80301
*No Well Eye Exams or Optical Department

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

LAFAYETTE

300 Exempla Circle
Suite 120
Lafayette, CO 80026
(Located within Exempla Community Physicians Pavilion)

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

LONGMONT

1400 Dry Creek Drive
Longmont, CO 80503

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

GREELEY

1616 15th Street
Greeley, CO 80634
(Located within Welch Eye Clinic)
*No Well Eye Exams or Optical Department

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

© Copyright Eye Care Center of Northern Colorado

Thank you for being patient and kind

COVID-19 has created challenges across the healthcare industry. You may experience slower response times for non-urgent services at our clinics.

Step 1 of 7

14%

What is your age range?*
- Under 18
- 18 - 39
- 40 - 49
- 50+

Without my glasses and contacts...*
check all that apply
- I struggle to drive and see things far away‎ (Nearsighted)
- I struggle to read and see things up close (Farsighted)
- I have distorted vision and cannot see very well‎ (Astigmatism)

What do you usually wear to see?*
check all that apply
- Glasses
- Contacts
- Reading Glasses
- Nothing

Do you have any of the following?*
check all that apply
- Prior Eye Surgery‎
- Prior serious eye injury‎
- Rheumatoid Arthritis‎
- Cataracts‎
- Lupus‎
- Keratoconus‎
- Are you pregnant or nursing?‎
- None of the above‎
It would be best to wait until after your baby is born before undertaking one of our surgical procedures.

I would like to see well at a distance without relying on glasses and contact lenses.
Rate this statement on a scale of 1 to 5 with 1 being the lowest.

I would like to see well up close without relying on glasses and contact lenses.
Rate this statement on a scale of 1 to 5 with 1 being the lowest.

Looks like you are a great candidate for LASIK!

Please complete the form below so we can setup a consultation!
You may not be a good candidate for Lasik… BUT, we can look at one of our other refractive surgical procedures as an option.

Please complete the form below so we can setup a consultation for your best options!
Name*
First Last
Email
Phone
Message

Step 1 of 2

50%

Are you experiencing?
- Clouded, blurred, or dim vision?
- Difficulty seeing distant objects?
- Sensitivity to light or glare?
- Difficulty seeing distant objects?
- Seeing a halo around lights?
- Fading or yellowing of colors?
Has your prescription for eyeglasses changed more often than usual?
- Yes
- No
Do you need brighter light for reading?
- Yes
- No
Does your vision sometimes seem distorted?
- Yes
- No
Have you experienced double vision in one eye only?
- Yes
- No
Do you see “ghost” images?
- Yes
- No
How do you prefer to have a member of our clinic’s staff follow up and contact you?
- Phone
- Email

Name*
First Last
Phone*
Email
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