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:

Date Of Birth*

Phone Number:*

Email:*

Parent/Guardian:

Address:*

Reason for Referral:*

If Neuro-Optometric Rehabilitation or vision therapy is ordered/recommended, please select one of the following:

1. Co-Manage (occupational/physical therapists) neuro-optometric rehabilitation care (vision therapy) if ordered/recommended by a Swoop Eye Care provider.
2. No, I would like Swoop and vision therapy partner organization (NeuVision) to manage the patient’s neuro-optometric care. Patient to return for routine eye care.
3. No, I would like Swoop and partner (NeuVision) to manage both Neuro-Optometric and routine eye care moving forward.

1. Co-Manage2. Partner Organization with Patient's neuro-optometric Care3. Manage both By Swoop Eye Care

Upload/Attach Exam, School Form or other important documents:

Patient Insurance Information:

Insurance Name