Referring Providers Form

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

  1. 1. Co-Manage (occupational/physical therapists) neuro-optometric rehabilitation care (vision therapy) if ordered/recommended by a Swoop Eye Care provider.
  2. 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. 3. No, I would like Swoop and partner (NeuVision) to manage both Neuro-Optometric and routine eye care moving forward.
Upload/Attach Exam, School Form or other important documents:
Patient Insurance Information:
Insurance Name