Appointment Request This portal is for referring providers only. If you are a patient, please call your preferred office to schedule your appointment. Referring Provider*NPI Number*Practice NameOffice Contact*Phone*Fax- Where progress notes can be faxed to*Patient Name* First Last Patient Phone*Patient Date of Birth* Patient Primary Insurance*HMO?*YesNoPatient Secondary 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 Time*Immediately-*Please call our office to confirm schedulingWithin one weekWithin one monthWhen patient prefersOtherRequest Appointment Location*BakersfieldLompocOxnardPalmdalePaso RoblesSan Luis ObispoSanta BarbaraSanta MariaValenciaVisaliaWestlake VillageNotes Drop files here or Please upload a copy of the referring provider's office notes. Insurance Information Drop files here or Please upload a copy of the front and back of insurance card. If it is an HMO, please upload a copy of the authorization.