Boulder & Longmont
:
303-402-1000
Arvada, Denver, & Parker:
303-794-1111
Littleton:
303-991-9662
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InSight Vision Group Arvada
InSight LASIK Boulder
InSight Vision Group Boulder
InSight Vision Group Denver – Yale
InSight Vision Group Littleton
InSight Vision Group Longmont
InSight LASIK Parker near Lone Tree
InSight Vision Group Parker near Lone Tree
Services
Advanced Dry Eye
Cataracts
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Corneal Cross Linking
Glaucoma
ICL
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Userid
Is this Referral Urgent
Yes
No
Treatment Category
Cataracts
Glaucoma
LASIK/PRK
Corneal Cross-Linking
ICL - Implantable Collamer Lens
Vitreolysis Floater Treatment
Serum Tears
Advanced Dry Eye
Testing
Location
Option 1
Option 2
Date
*
Doctor's Name
*
Contact Email
*
Phone Number
*
Fax Number
Preferred Method of Communication
*
Email
Fax
Letter
Patient's First Name
*
Patient's DOB
Patient's Last Name
*
Patient's Email Address
*
Patient's Phone Number
*
Med Insurance
Member ID
Group Number
Phone Number For Providers
InSight Vision Group
*
One-Time Consult
Diagnose and Treat Problem
Co-Manage
Follow Patient along with me
Transfer Complete Management
I will follow Routine Care Only
Doctor Preferences
*
Greg Kouyoumdjian, MD
Teresa Carlson, OD
Starck Johnson, MD
Crystal Kasper, OD
Ketty Lee, OD
Mike Bollenbacher, OD
Robert Prouty, OD
Richard Stewart, MD
Carl Tubbs, MD
Thomas Cruse, OD
First Available
Isha Gupta, MD
Reason For Referral
*
Comment
For Cataract Surgery Referrals Only
New technology IOLs, LenSx, and ORA were discussed with my patient and I recommend the following for my patient:
Standard IOL
Toric Package
ReSTOR Package
PanOptix Trifocal Package
Crystalens Package
Trulign Toric-Accomodating Package
Symfony Package
LenSX
ORA
LenSX and ORA
Who does the post-op cataract care?
Referring OD
Surgeons Office
Distance Eye Is
OD
OS
Monovision Near Eye
OD
OS
Near Eye Target
Secondary Cataract YAG Treatment
OD
OS
Comment
Comment
Coordination of Glaucoma Care
One-time consult
Diagnose and treat this problem
Co-manage
Transfer complete management
I will follow your routine care only
Other
Glaucoma Doctor Preference
Robert Prouty, OD
Richard Stewart, MD
Carl Tubbs, MD
Teresa Carlson, OD
Tom Cruse, OD
Isha Gupta, MD
First Available
Comment
Visual Fields
Humphrey 24-2
Humphrey 10-2
Nerve Fiber Analysis
Cirrus (Zeiss)
Avanti (OptoVue) OCT of ONH & macula scan (GCC)
Other
Pentacam
Avanti Angle OCT Scan
Digital Fundus Photos
Immersion A-Scan
IOL Master High Resolution B-Scan
High End Resolution B-Scan
Endothelial Cell Count
LenStar
Test Results
With Interpretation
Without Interpretation
Diagnosis Code
File Upload
File Upload 2
File Upload 3
File Upload 4
File Upload 5
Who does the post-op cataract care?
Referring OD
Surgeons Office
Surgeon Preference
C. Starck Johnson
Richard Stewart
Patient Choice
Location Preference
Parker
Boulder
Monovision Discussed
Yes
Trialed in Contact Lenses (Please attach records.)
No
Comments
Patient Wears
Glasses
Contacts
Scleral
Rigid Gas Perm
Consider Treatment For:
OD
OS
OU
Diagnosis
Keratoconus
Ectasia
Comments
Manifest Refraction OD
Manifest Refraction OS
Patient Wears
Glasses
Contacts
Scleral
Rigid Gas Perm
Consider Treatment For:
OD
OS
OU
Comments
Patient Has Floaters
OD
OS
OU
Have The Floaters:
Recently Appeared
Been There For Awhile
Are The Floaters Impairing The Patient's Vision?
Yes
No
Has The Patient Had Previous Eye Surgery?
Yes
No
Comments
Patient Needs Tears For:
OD
OS
OU
Percent of Serum
30/70
50/50
I Recommend Patient Obtain A
Three-month supply (approximately 6 bottles for OU)
Six-month supply (approximately 12 bottles for OU)
Supply Per Patient's Decision
Comments
What Current Therapies Have Been Tried?
Punctal Plugs
Serum Tears
Amniotic Membrane
IPL
LipiFlow
Fish Oil
Other
Comments
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Schedule an Appointment
×
Preferred Date
*
Are you a current patient?
*
Yes
No
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Date of Birth
Preferred Location
*
InSight Parker
InSight Denver - Yale
InSight Boulder
InSight Littleton
InSight Longmont
InSight Arvada
InSight LASIK South
InSight LASIK North
I currently wear (check as many that apply)
Soft Contacts
Gas Permeable Contacts
Glasses
Readers
I am
Nearsighted
Farsighted
Astigmatic
Please describe the nature of your appointment (e.g., consultation, check-up, etc)
*
Submit
LASIK Candidacy Survey
×
Please complete the following questions to help us provide you with an appropriate response.
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Who is your current eye doctor?
Date of Birth
Which location would you prefer?
*
LASIK Parker Office
LASIK Boulder Office
I wear glasses and contacts because (check all that apply)
I have trouble reading and seeing things up close
I have trouble driving and seeing things far away
I have astigmatism
What do you usually wear (check all that apply)
Glasses
Contacts
Reading Glasses
I don't wear correction and probably should
Have you ever had (check all that apply)
Previous Eye Surgery
A serious eye injury
Cataracts
Keratoconus
Diabetic Retinopathy
Where do you live your visual life (check all that apply)
I love the outdoors and am active
I love reading
I love participating in sports
I spend hours on my computer
What are your expectations after LASIK? (check all that apply)
I am fine wearing glasses for distance
I do not want to wear glasses for distance
I am fine wearing glasses for up close and reading
I do not want to wear glasses for seeing up close
Would you be willing to review your level of candidacy with one of our InSight LASIK Counselors?
*
Yes
No
Submit