Patient & Referring Doctor Information

Thank You for Your Trust

It would be our privilege to accept your referrals.

Quick, easy, HIPAA compliant online referral process!
No faxing or calling. Simply fill out the short form below & your patient will be contacted within one (1) business day.
We will request that your patients return to you for annual eye exams upon completion of their post-operative care.
If the patient is need of any eyewear we will direct them to your practice; we do NOT have an optical department.

$Refractive Procedures:$

Refractive Procedures:

LASIK & PRK

Ages 18 - 60 ish
Health eyes, no onset of cataracts.
Myopia up to -12D and up to -6D of astigmatism.
Hyperopia up to +5D and up to -3D of astigmatism.

EVO ICL
Ages 21-45
Myopia starting as low as -3D up to -20D. Astigmatism up to -4.0D.
Not for hyperopia or presbyopia.

Oculoplastics

Oculoplastics requires extreme precision. That’s why we provide an un-rushed approach to fully evaluate your patient’s visual needs, lifestyle & aesthetic desires. Then Dr. Valerie H. Chen can make personalized recommendations for each patient that will meet his or her individual goals. This plan may involve non-surgical and/or surgical recommendations. Dr. Chen specializes in Ptosis, Entropion, Ectropion, Blepharoplasty, and post-Mohs reconstruction.

Treatment for Kerataconus

Keratoconus (kehr-uh-toh-koh-nus) is a condition where the cornea—the clear, dome-shaped surface of the eye—thins and becomes irregularly shaped, causing a cone-like bulge. This results in distorted vision and symptoms such as:

Blurred vision
Sensitivity to light
Double vision
Thinning or bulging of the cornea

Patient & Referring Doctor Information

Please fill out the short form below to provide information on yourself and your patient. This form is HIPAA compliant.

Records welcomed. Fax 704-540-9616 or email [email protected]

Patient First Name

Patient Last Name

Patient Email Address

Patient Phone Number

Patient Birthdate

Being Referred For

Referring Doctor

Referring Practice

Please provide any specifics about the patients eyes, vision and/or desired procedure.

Sending... Please complete all required fields

Communication with our office through this website is not for the purpose of asking questions regarding a particular health concern or issue, and neither future patients nor active patients should use this website as a method to gather advice or make Providence Eye & Laser Specialists aware of any medical condition that requires attention. All such communication should be strictly made by telephone. Although we attempt to answer all communication through this website, there is no guarantee it will be electronically delivered in a timely fashion or at all, and we cannot guarantee a response to all submissions.

Thank you for referring your patient to us, we consider it an honor. Your patient will be contacted by our team within 1 business day. If you have any questions you are always welcome to call us at (704) 540-9595 and fax records to 704-540-9616.