Refractive Surgery Consultation Request
For LASIK, PRK, EVO ICL, and refractive lens exchange referrals.
Download PDFFor Referring Optometrists
Printable Forms
All forms below are fillable and printable PDFs — co-management and referral forms for optometrists, plus consent forms and guides for patients.
Completed forms can be faxed to 818-845-1916
or emailed to info@bergfeinfield.com
OD Co-Management Forms
Referral and co-management forms for our partnering optometrists.
Medical Consultation Referral
For cornea, glaucoma, cataract, and general medical eye care referrals.
Download PDFPre-Operative Form
Co-management pre-operative documentation for your referred patients.
Download PDFPost-Operative Form
Co-management post-operative documentation for follow-up care.
Download PDFBFVC Info Pad
A patient-facing information pad to give to patients you refer.
Download PDFInsurance Cheat Sheet
A quick reference for insurance and coverage questions.
Download PDFPatient Forms
Consent forms, pre-operative instructions, and guides for patients.
LASIK Consent Form
Informed consent for LASIK laser vision correction.
Download PDFPRK Consent Form
Informed consent for PRK laser vision correction.
Download PDFLASIK / PRK Pre-Operative Instructions
What patients need to know and do before their procedure.
Download PDFVision for Life Patient Guide
The Vision for Life long-term care program agreement and guide.
Download PDFPrivacy Notice
Our notice of privacy practices (HIPAA) for patients.
Download PDFDisclaimer: These forms and resources are provided for the use of referring providers and their patients. General information on practice development and medical billing is intended for educational purposes only and should not be relied upon as a source for legal or medical advice.