Appointment Request This portal is for referring providers only. If you are a patient, please call your preferred office to schedule your appointment. "*" indicates required fields Referring Provider* Provider Phone Number*Referring Provider Email Provider Fax Number*Patient Name* First Last Patient Phone Number*Patient Alternate Phone NumberPatient Date of Birth* MM slash DD slash YYYY Patient Primary Insurance Which Eye(s) is Patient Being Seen For?*OSODOUReason for Referral* Wet AMD Dry AMD Retinal Tear Epiretinal Membrane Diabetic Macular Edema Proliferative Diabetic Retinopathy NonProliferative Diabetic Retinopathy Vitreous Hemorrhage Macular Hole Other Addtional/Other Reason for Referral(If not shown above)Request Appointment TimeImmediately-*Please call our office to confirm schedulingWithin one weekWithin one monthWhen patient prefersOtherRequest Appointment Location*Request a LocationBakersfieldLompocOxnardPalmdalePaso RoblesSan Luis ObispoSanta BarbaraSanta MariaSimi ValleyValenciaVisaliaWestlake VillageNotes Drop files here or Select files Max. file size: 50 MB. Please upload a copy of the referring provider's office notes. Insurance Information Drop files here or Select files Max. file size: 50 MB. Please upload a copy of the front and back of insurance card. If it is an HMO, please upload a copy of the authorization.
