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Referring Provider Information

Referring Doctor Credentials

Referring Practice Location

Multi-line address
Preferred Treating Physician (Optional)
Brett Rhode, MD
Daniel Ferguson, MD
Daniel Paskowitz, MD, PhD
Michael Raciti, MD
Any Available Physician

Patient Information

Patient Date of Birth
Month
Day
Year

Patient Address & Location

Multi-line address
Gender
Interpreter Needed?
Patient Preferred Location
Urgent Referral (ex: pain, severe redness, flashes of light/new floaters, etc.)
No
Yes
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Co-Management Preferences

Following our evaluation, we will communicate any findings and/or treatment recommendations. If surgery is necessary, please indicate below if you would like to co-manage. Regardless, all patients will be sent back to the referring provider to resume general eye care, as appropriate.

If surgery is recommended, I'd like to co-manage the patient's post-op care if the surgeon feels medically appropriate.
No
Yes
If surgery is recommended, I'd prefer Eye Care Specialists to assume the patient's post-op care and will resume the general care of the patient after the post-op period.
No
Yes

Secure Referral Submission: Information submitted through this form is securely transmitted and intended solely for patient care and care coordination.

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Downtown

633 W. Wisconsin Avenue

Milwaukee, WI 53203

414-298-0099

West Allis

2601 S. 102nd Street 

West Allis, WI 53227

414-321-7520

Mayfair

2323 N. Mayfair Road

Wauwatosa, WI 53226

414-258-4550

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The material contained on this site is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
 

Always seek the advice of your physician or other qualified health care provider.

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