Referring Providers Form for Swoop Eye Care

Online Referral Form

Hello, and welcome to Swoop Eye Care's patient online referral form! For immediate assistance or urgent referral, please contact our office at (612) 488-1566. Please complete the information as best as possible.

Referring Provider:

Patient's Information:

Parent/Guardian:

Please select the most appropriate optometrist or select the soonest available.*

Soonest Available OptometristDr. Michael Wallerich, OD (Neuro-Optometrist)Dr. Kelsey Sieg, OD (Neuro-Optometrist)

Reason for Referral:*

Following the neuro-optometry evaluation, we will send a report and treatment recommendations. If Neuro-Optometric Rehabilitation (vision therapy) is recommended/ordered, please select the most appropriate option to co-manage.

Choose option 3 if you prefer Swoop Eye Care to continue specialty/routine eye care after neuro-optometric care provided.

Co-Manage (occupational/physical therapists) rehabilitative care if ordered/recommended by Swoop neuro-optometrist.Co-Manage (optometrists/ophthalmologists) with Swoop Eye Care & NeuVision Therapy to provide neuro-optometry & neuro-optometric rehabilitation care (vision therapy) as recommended. Patient to return for routine eye care to your office.Manage/continue neuro-optometry & routine eye care with Swoop Eye Care & NeuVision Therapy & Rehabilitation following evaluation.

Upload/Attach Exam, relevant documents, and/or necessary forms or fax to (612) 488-1564:

Patient Insurance Information:

Insurance Name

Date:*

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