{"id":1545,"date":"2023-11-23T18:58:38","date_gmt":"2023-11-23T18:58:38","guid":{"rendered":"https:\/\/retinaconsultants-socal.com\/?page_id=1545"},"modified":"2023-11-23T21:03:44","modified_gmt":"2023-11-23T21:03:44","slug":"patient-referral","status":"publish","type":"page","link":"https:\/\/retinaconsultants-socal.com\/patient-referral\/","title":{"rendered":"Patient Referral"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column width=&#8221;1\/12&#8243;][\/vc_column][vc_column width=&#8221;5\/6&#8243;]\r\n<style type=\"text\/css\">\r\n\r\nbody #wpforms-1539 {\r\n\t\t\t}\r\n\r\n\r\n\r\n\r\n\r\n\tbody #wpforms-1539 .wpforms-submit-container .wpforms-submit, body #wpforms-1539 .wpforms-field-pagebreak button.wpforms-page-button {\r\n\t\theight:50px ;text-align:center ;background-color:#f77700 ;width:200px ;border-radius:10px ;-web-border-radius:10px ;-moz-border-radius:10px ;\t\tborder-width: 0px;\t}\r\n\tbody #wpforms-1539 .wpforms-submit-container .wpforms-submit:hover, body #wpforms-1539 .wpforms-field-pagebreak button.wpforms-page-button:hover {\r\n\t\t\t}\r\n\tbody #wpforms-1539 .wpforms-submit-container,body #wpforms-1539 .wpforms-field-pagebreak .wpforms-pagebreak-left{\r\n\ttext-align:center;\t}\r\n\r\n\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field input[type=text],\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field input[type=email],\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field input[type=tel],\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field input[type=url],\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field input[type=password],\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field input[type=number]\r\n\t{\r\n\t\tborder-radius:10px ;-web-border-radius:10px ;-moz-border-radius:10px ;\t\tborder-width: 1px;\t}\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field .wpforms-field-row\r\n\t{\r\n\t\t\t}\r\n\t\r\n\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field textarea {\r\n\t\twidth:970px ;border-radius:10px ;-web-border-radius:10px ;-moz-border-radius:10px ;\t\t\tborder-width: 1px;\t\t\r\n\t}\r\n\r\n \r\n\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field select {\r\n\r\n\t\twidth:145px ;border-radius:10px ;-web-border-radius:10px ;-moz-border-radius:10px ;\t\tmax-width:100% ;border-width: 1px;\t}\r\n\r\n\t\/* dropdown styles on modern background *\/\r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field-select-style-modern .choices__inner{\r\n\t\twidth:145px ;border-radius:10px ;-web-border-radius:10px ;-moz-border-radius:10px ;\t\t\r\n\t}\r\n\r\n\t\/* background color on modern dropdown *\/\r\n\t\r\n \r\n\tbody #wpforms-1539 .wpforms-form .wpforms-field label.wpforms-field-label {\r\n\t\tfont-weight: bold;\t}\r\n\r\n\/* Styling for Tablets *\/\r\n@media only screen and (max-width: 800px) and (min-width:481px) {\r\n\t\r\n\r\n\r\n\t\tbody #wpforms-1539 .wpforms-form .wpforms-field textarea{\r\n\r\n\t\t\r\n\t\twidth:590px ;\t\t}       \r\n\r\n}\r\n\r\n@media only screen and (max-width: 480px){\r\n\t\r\n\r\n\r\n\r\n}\r\n\/*Option to add custom CSS *\/\r\n\r\n\r\n\r\n\r\n\t\t<\/style>\r\n\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-1539\"><form id=\"wpforms-form-1539\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1539\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/1545?wpforms_form_id=1539\" data-token=\"9a714a40d4517608f4509d13b2fe7fbd\" data-token-time=\"1728399618\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-1539-field_22-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_22\">Preferred Provider <\/label><select id=\"wpforms-1539-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\"><option value=\"Scott Grant, M.D\" >Scott Grant, M.D<\/option><option value=\"Sean D. Adrean, M.D.\" >Sean D. Adrean, M.D.<\/option><option value=\"Ash Pirouz, M.D.\" >Ash Pirouz, M.D.<\/option><option value=\"Hema Ramkumar, M.D.\" >Hema Ramkumar, M.D.<\/option><option value=\"Caleb C. Ng, M.D.\" >Caleb C. Ng, M.D.<\/option><option value=\"Chang Sup Lee, M.D.\" >Chang Sup Lee, M.D.<\/option><\/select><\/div><div id=\"wpforms-1539-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Referring Doctor* <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1539-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-1539-field_1-error\" required><label for=\"wpforms-1539-field_1\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1539-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-1539-field_1-last-error\" required><label for=\"wpforms-1539-field_1-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1539-field_8-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"8\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1539-field_9-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_9\">Referring Office Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1539-field_9\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][9]\" placeholder=\"(000) 000 -0000\" aria-errormessage=\"wpforms-1539-field_9-error\" aria-describedby=\"wpforms-1539-field_9-description\" required><div id=\"wpforms-1539-field_9-description\" class=\"wpforms-field-description\">Please enter a valid phone number.<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1539-field_7-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_7\">Referring Office Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1539-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1539-field_7-error\" aria-describedby=\"wpforms-1539-field_7-description\" required><div id=\"wpforms-1539-field_7-description\" class=\"wpforms-field-description\">example@example.com<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1539-field_10-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Patient Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1539-field_10\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][10][first]\" aria-errormessage=\"wpforms-1539-field_10-error\" required><label for=\"wpforms-1539-field_10\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1539-field_10-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][10][last]\" aria-errormessage=\"wpforms-1539-field_10-last-error\" required><label for=\"wpforms-1539-field_10-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1539-field_13-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"13\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1539-field_11-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Patient DOB<\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][11][date][m]\" id=\"wpforms-1539-field_11-month\" class=\"wpforms-field-date-time-date-month\" aria-label=\"Month\" ><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][11][date][d]\" id=\"wpforms-1539-field_11-day\" class=\"wpforms-field-date-time-date-day\" aria-label=\"Day\" ><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][11][date][y]\" id=\"wpforms-1539-field_11-year\" class=\"wpforms-field-date-time-date-year\" aria-label=\"Year\" ><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1539-field_14-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_14\">Patient Phone* <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1539-field_14\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][14]\" placeholder=\"(000) 000 -0000\" aria-errormessage=\"wpforms-1539-field_14-error\" aria-describedby=\"wpforms-1539-field_14-description\" required><div id=\"wpforms-1539-field_14-description\" class=\"wpforms-field-description\">Please enter a valid phone number.\r\n<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1539-field_15-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_15\">Patient Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1539-field_15\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][15]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1539-field_15-error\" aria-describedby=\"wpforms-1539-field_15-description\" required><div id=\"wpforms-1539-field_15-description\" class=\"wpforms-field-description\">example@example.com<\/div><\/div><div id=\"wpforms-1539-field_16-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"16\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1539-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_17\">Vision RE<\/label><input type=\"text\" id=\"wpforms-1539-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-1539-field_17-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1539-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_18\">Vision LE<\/label><input type=\"text\" id=\"wpforms-1539-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" aria-errormessage=\"wpforms-1539-field_18-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1539-field_21-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_21\">Suspected problems or symptoms<\/label><textarea id=\"wpforms-1539-field_21\" class=\"wpforms-field-small\" name=\"wpforms[fields][21]\" placeholder=\"Type Here...\" aria-errormessage=\"wpforms-1539-field_21-error\" ><\/textarea><\/div><div id=\"wpforms-1539-field_20-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-1539-field_20\">Please upload any drawings, face sheets, diagnostic imaging, and exam notes<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"20\"\n\t\tdata-form-id=\"1539\"\n\t\tdata-input-name=\"wpforms_1539_20\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,svg\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to 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