{"id":489,"date":"2025-02-05T20:29:57","date_gmt":"2025-02-05T20:29:57","guid":{"rendered":"https:\/\/hautevision.com\/contact-us\/"},"modified":"2026-04-02T14:51:40","modified_gmt":"2026-04-02T18:51:40","slug":"referral","status":"publish","type":"page","link":"https:\/\/hautevision.com\/en\/referral\/","title":{"rendered":"Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"489\" class=\"elementor elementor-489\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0b162e6 e-flex e-con-boxed e-con e-parent\" data-id=\"0b162e6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-a68e696 e-flex e-con-boxed e-con e-child\" data-id=\"a68e696\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7a01b55 elementor-widget elementor-widget-heading\" data-id=\"7a01b55\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Referral Request<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a5158c8 elementor-widget elementor-widget-spacer\" data-id=\"a5158c8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ab73528 elementor-widget elementor-widget-text-editor\" data-id=\"ab73528\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"font-weight: 400;\">Simply fill out the form below and we will schedule an appointment with your patient.<\/span><\/p><p>You can also download the form in PDF format.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-90a17c0 elementor-widget elementor-widget-button\" data-id=\"90a17c0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"\/wp-content\/uploads\/consultation-request-2026-en.pdf\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"20.462\" height=\"9\" viewBox=\"1178.926 804.5 20.462 9\"><path d=\"m1194.913 804.5-1.425 1.4 2.075 2.1h-16.637v2h16.637l-2.1 2.1 1.425 1.4 4.5-4.5-4.475-4.5Z\" fill-rule=\"evenodd\" data-name=\"Trac&#xE9; 25\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Download the PDF<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-bd2ddf7 e-con-full e-flex e-con e-child\" data-id=\"bd2ddf7\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-965e83d elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"965e83d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;button_width&quot;:&quot;33&quot;,&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Referral\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"489\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"965e83d\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Referral - Haute Vision\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"489\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_48f36c8 elementor-col-100\">\n\t\t\t\t\t<h2>Referring to<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-first_name elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[first_name]\" id=\"form-field-first_name\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Dr : (Specify)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f14d080 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f14d080\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tno preference\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No Preference for Doctor \/ Please assign according to availability\" id=\"form-field-field_f14d080-0\" name=\"form_fields[field_f14d080]\"> <label for=\"form-field-field_f14d080-0\">No Preference for Doctor \/ Please assign according to availability<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b77dbf3 elementor-col-100\">\n\t\t\t\t\t<h2>Patient Details<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patient_fn elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patient_fn]\" id=\"form-field-patient_fn\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"First Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patient_ln elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patient_ln]\" id=\"form-field-patient_ln\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Last Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-patient_phone elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[patient_phone]\" id=\"form-field-patient_phone\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Tel. #1\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_06dff8f elementor-col-100\">\n\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_06dff8f]\" id=\"form-field-field_06dff8f\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Tel. #2\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-patient_bd elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[patient_bd]\" id=\"form-field-patient_bd\" class=\"elementor-field elementor-size-lg  elementor-field-textual elementor-date-field\" placeholder=\"Date of birth\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3ca7253 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3ca7253]\" id=\"form-field-field_3ca7253\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"RAMQ #\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_7613732 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7613732\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tGender\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"M\" id=\"form-field-field_7613732-0\" name=\"form_fields[field_7613732]\" required=\"required\"> <label for=\"form-field-field_7613732-0\">M<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"F\" id=\"form-field-field_7613732-1\" name=\"form_fields[field_7613732]\" required=\"required\"> <label for=\"form-field-field_7613732-1\">F<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f9e38ae elementor-col-100\">\n\t\t\t\t\t<h2>Referral reason<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-reasons elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"General \" id=\"form-field-reasons-0\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-0\">General <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cataract \" id=\"form-field-reasons-1\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-1\">Cataract <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Retina \" id=\"form-field-reasons-2\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-2\">Retina <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Glaucoma \" id=\"form-field-reasons-3\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-3\">Glaucoma <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cornea \" id=\"form-field-reasons-4\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-4\">Cornea <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Dry Eyes\" id=\"form-field-reasons-5\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-5\">Dry Eyes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Advanced Dry Eye Therapy (IPL, RF, amniotic membrane, PRP drops, scleral lenses)\" id=\"form-field-reasons-6\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-6\">Advanced Dry Eye Therapy (IPL, RF, amniotic membrane, PRP drops, scleral lenses)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Oculoplastics\/Esthetics (blephs, lid lesions, xanthelasma, injections, rejuvenation)\" id=\"form-field-reasons-7\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-7\">Oculoplastics\/Esthetics (blephs, lid lesions, xanthelasma, injections, rejuvenation)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Refractive Surgery (refractive lens exchange, LASIK\/PRK, EVO\/intraocular contact lens)\" id=\"form-field-reasons-8\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-8\">Refractive Surgery (refractive lens exchange, LASIK\/PRK, EVO\/intraocular contact lens)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-reasons-9\" name=\"form_fields[reasons][]\"> <label for=\"form-field-reasons-9\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-other_reason elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[other_reason]\" id=\"form-field-other_reason\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Other(s): Please specify\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_18a6319 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Loss of vision\" id=\"form-field-field_18a6319-0\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-0\">Loss of vision<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"OD\" id=\"form-field-field_18a6319-1\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-1\">OD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"OS\" id=\"form-field-field_18a6319-2\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-2\">OS<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"OU\" id=\"form-field-field_18a6319-3\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-3\">OU<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Gradual\" id=\"form-field-field_18a6319-4\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-4\">Gradual<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sudden\" id=\"form-field-field_18a6319-5\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-5\">Sudden<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Transient\" id=\"form-field-field_18a6319-6\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-6\">Transient<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Constant\" id=\"form-field-field_18a6319-7\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-7\">Constant<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Curtain\" id=\"form-field-field_18a6319-8\" name=\"form_fields[field_18a6319][]\"> <label for=\"form-field-field_18a6319-8\">Curtain<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6715df7 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6715df7]\" id=\"form-field-field_6715df7\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"How long and since when?\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6ef8562 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pain\" id=\"form-field-field_6ef8562-0\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-0\">Pain<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Flashes of light\" id=\"form-field-field_6ef8562-1\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-1\">Flashes of light<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"New floater(s)\" id=\"form-field-field_6ef8562-2\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-2\">New floater(s)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Metamorphopsia \/ Distortion\" id=\"form-field-field_6ef8562-3\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-3\">Metamorphopsia \/ Distortion<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Photophobia\" id=\"form-field-field_6ef8562-4\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-4\">Photophobia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tearing\" id=\"form-field-field_6ef8562-5\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-5\">Tearing<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Foreign body sensation\" id=\"form-field-field_6ef8562-6\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-6\">Foreign body sensation<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Itching and burning\" id=\"form-field-field_6ef8562-7\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-7\">Itching and burning<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Redness\" id=\"form-field-field_6ef8562-8\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-8\">Redness<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Swollen lids\" id=\"form-field-field_6ef8562-9\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-9\">Swollen lids<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Discharge\" id=\"form-field-field_6ef8562-10\" name=\"form_fields[field_6ef8562][]\"> <label for=\"form-field-field_6ef8562-10\">Discharge<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_fca0c10 elementor-col-100\">\n\t\t\t\t\t<h4>Refraction (Left Eye)<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_179fb05 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_179fb05]\" id=\"form-field-field_179fb05\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Sphere\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_454a7ca elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_454a7ca]\" id=\"form-field-field_454a7ca\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Cylinder\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_49d7f86 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_49d7f86]\" id=\"form-field-field_49d7f86\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Axis\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d50e064 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d50e064]\" id=\"form-field-field_d50e064\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"VA\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_17307d0 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_17307d0]\" id=\"form-field-field_17307d0\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"IOP\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8467803 elementor-col-100\">\n\t\t\t\t\t<h4>Refraction (Right Eye)<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3382166 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3382166]\" id=\"form-field-field_3382166\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Sphere\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a4c7b7f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a4c7b7f]\" id=\"form-field-field_a4c7b7f\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Cylinder\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_758680a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_758680a]\" id=\"form-field-field_758680a\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Axis\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8c2cbfa elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8c2cbfa]\" id=\"form-field-field_8c2cbfa\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"VA\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6fd3b7b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6fd3b7b]\" id=\"form-field-field_6fd3b7b\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"IOP\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c4b8ee1 elementor-col-100\">\n\t\t\t\t\t<h4>Eyewear<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_0a6935d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0a6935d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEyewear\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Glasses\" id=\"form-field-field_0a6935d-0\" name=\"form_fields[field_0a6935d]\"> <label for=\"form-field-field_0a6935d-0\">Glasses<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Contact lenses\" id=\"form-field-field_0a6935d-1\" name=\"form_fields[field_0a6935d]\"> <label for=\"form-field-field_0a6935d-1\">Contact lenses<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Prism\" id=\"form-field-field_0a6935d-2\" name=\"form_fields[field_0a6935d]\"> <label for=\"form-field-field_0a6935d-2\">Prism<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-comments elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-comments\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tComments\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-lg\" name=\"form_fields[comments]\" id=\"form-field-comments\" rows=\"4\" placeholder=\"Comments\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_5e9e6bc elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e9e6bc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tClinical information:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-lg\" name=\"form_fields[field_5e9e6bc]\" id=\"form-field-field_5e9e6bc\" rows=\"4\" placeholder=\"Clinical information:\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_857d5fb elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_857d5fb\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPrevious\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-lg\" name=\"form_fields[field_857d5fb]\" id=\"form-field-field_857d5fb\" rows=\"4\" placeholder=\"Previous ocular surgery \/ disease: \"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_063ec5e elementor-col-100\">\n\t\t\t\t\t<h4>Referred by: <\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bfb71f9 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bfb71f9]\" id=\"form-field-field_bfb71f9\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Last Name: \">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1614035 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1614035]\" id=\"form-field-field_1614035\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"First Name: \">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6ffd118 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6ffd118]\" id=\"form-field-field_6ffd118\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"License #\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cab2df6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cab2df6]\" id=\"form-field-field_cab2df6\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Fax #\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_324f19b elementor-col-100 recaptcha_v3-bottomright\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_324f19b\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LcGA_4qAAAAACOysq-sCNzVUbtb7N2wsPxecrBt\" data-type=\"v3\" data-action=\"Form\" data-badge=\"bottomright\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-33 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-lg\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"20.462\" height=\"9\" viewBox=\"1178.926 804.5 20.462 9\"><path d=\"m1194.913 804.5-1.425 1.4 2.075 2.1h-16.637v2h16.637l-2.1 2.1 1.425 1.4 4.5-4.5-4.475-4.5Z\" fill-rule=\"evenodd\" data-name=\"Trac&#xE9; 25\"><\/path><\/svg>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Referral Request Simply fill out the form below and we will schedule an appointment with your patient. You can also download the form in PDF format. 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