Patient Online Referral

This is a referral portal intended for optometrists to refer their patients to Chu Vision Institute.
For emergency referrals, please contact our office at (952) 835-1235.

Streamlined Patient Referrals for Optometrists

Use our secure portal to quickly refer patients to Chu Vision Institute for specialized care. Your partnership ensures they receive prompt, expert attention.

Referring Doctor

Doctor's First Name* This field is required.

Doctor's Last Name* This field is required.

Practice Name* This field is required.

Practice Location* This field is required.

Email*

Is this a new patient referral?*

Yes - New Patient To Chu Vision

No - Returning Chu Vision Patient

If unsure, select yes.

Patient Demographics

Patient Date of Birth* This field is required.

Patient's First Name* This field is required.

Patient's Last Name* This field is required.

Patient's Phone* This field is required.

Patient's Email* This field is required.

Reason for Referral* This field is required.

Additional Comments

Patient Exam Upload

Upload exam or additional information.

This field is required.

By completing this form, you are giving us permission to follow-up by phone, email or text.

This field is required.

Submit

Patient Online Referral

Streamlined Patient Referrals for Optometrists

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