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 Name*Office Contact*Phone*Fax- Where progress notes can be faxed to*Patient Name First Last Patient PhonePatient Date of Birth Patient Primary InsuranceHMO?YesNoPatient Secondary InsuranceWhich 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 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 LocationBakersfieldLompocOxnardPalmdalePaso RoblesSan Luis ObispoSanta BarbaraSanta MariaValenciaVisaliaNotes 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.