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Zarmeena Vendal, M.D.
Natalie Stanciu, M.D.
Stanley Saulny, M.D.
Catherine Makin, M.D.
Andrew Plummer, M.D.
Liana Renteria, O.D.
Austin Ophthalmologists
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OD Referral Form
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OD Referral Form
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Last Name
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Patient Information
Patient Information
Date of Birth
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Phone
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Patient Email
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Date of Exam
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Referring Doctor
Referring Doctor
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Practice
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NPI
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Fax
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Location For Referral
Austin
New Braunfels
Kyle
Reason for Referral
Oculoplastics
Strabismus
Cornea
Glaucoma
Refractive
Yag Cap / PCO eval
Cataract
Other
Preferred Consulting Westlake Eye Specialists Physician Team
I have a Preferred Consulting Westlake Eye Specialists Physician Team
I have no team preference
Preferred Consulting Westlake Eye Specialists Physician Team.
(Please indicate Surgeon name)
We will do our best to match your preferred referral request, and is not a guarantee. Patients may be directed to an alternate referring provider/team member due to scheduling needs.
Clinical findings/areas of concern:
How do you want your patients co-managed? Choose one. If a selection is not made, your patient will be co-managed by Westlake Eye Specialists.
(Required)
Patient wishes to return to my office for post-op care.
Patient prefers Westlake Eye Specialists to manage surgical post-op care.
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Pertinent history/risk factors/additional requests
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