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Appointment is already scheduled: Date:
Please call my patient to schedule: Phone Number:
                                                            Insurance:
                                                            Insurance Number:


I am referring my patient to you for:
Cataract
Glaucoma
LASIK / Refractive Surgery
Diabetic / Retina Eval
Other:

Patient wishes to be comanaged - Form Attached
Patient does not wish to be comanaged
Please manage this patient on an ongoing basis, I will see the patient for routine care
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