Home
About Us
Laura S. Kearsley, MD
Philip M. Brunetti, MD
Jason Croskrey, MD – Coming Soon!
Mark W. Lantz, OD
Danica M. Lantz, OD
Our Staff
Procedures
Cataract Surgery
Secondary Cataract Laser Treatment
Toric IOL
Multifocal IOLs
LipiFlow
Minimally Invasive Surgery
Glaucoma Eye Laser Treatment
Topical Treatments
Blepharoplasty
Brow Pexy
Botox
Medical Retina
Avastin
Eylea
Lucentis
Ozurdex
Vabysmo
Diabetic Eye Laser Treatment
Laser Demarcation
SMILE
LASIK
Photorefractive Keratectomy
SMILE
Patient Education
Cataracts
Astigmatism
Macular Degeneration
Diabetic Eye Disease
Glaucoma
Uveitis
Floaters
Retinal Detachment
Vitreous Detachment
Macular Pucker
Blepharitis
Dry Eye
Fluorescein Angiography
Resources
Patient Portal
Documents and Forms
No Surprises Act
Financing
Alphaeon Credit
CareCredit
For Doctors
Podcast
Contact
Fairbanks: 907.328.2920
Request an Appointment
Home
About Us
Laura S. Kearsley, MD
Philip M. Brunetti, MD
Jason Croskrey, MD – Coming Soon!
Mark W. Lantz, OD
Danica M. Lantz, OD
Our Staff
Procedures
Cataract Surgery
Secondary Cataract Laser Treatment
Toric IOL
Multifocal IOLs
LipiFlow
Minimally Invasive Surgery
Glaucoma Eye Laser Treatment
Topical Treatments
Blepharoplasty
Brow Pexy
Botox
Medical Retina
Avastin
Eylea
Lucentis
Ozurdex
Vabysmo
Diabetic Eye Laser Treatment
Laser Demarcation
SMILE
LASIK
Photorefractive Keratectomy
SMILE
Patient Education
Cataracts
Astigmatism
Macular Degeneration
Diabetic Eye Disease
Glaucoma
Uveitis
Floaters
Retinal Detachment
Vitreous Detachment
Macular Pucker
Blepharitis
Dry Eye
Fluorescein Angiography
Resources
Patient Portal
Documents and Forms
No Surprises Act
Financing
Alphaeon Credit
CareCredit
For Doctors
Podcast
Contact
Fairbanks: 907.328.2920
Request an Appointment
Fairbanks, AK:
907.328.2920
Request an Appointment
Careers
About Us
About Us
Meet Our Surgeons
Laura S. Kearsley, MD
Philip M. Brunetti, MD
Jason Croskrey, MD
Meet Our Optometrists
Mark W. Lantz, OD
Danica M. Lantz, OD
Our Staff
Procedures
Procedures
Cataract
Cataract Surgery
Secondary Cataract Laser Treatment
Toric IOL
Multifocal IOLs
Dry Eye Treatment
LipiFlow
Glaucoma
Minimally Invasive Surgery
Glaucoma Eye Laser Treatment
Topical Treatments
Plastics
Blepharoplasty
Brow Pexy
Botox
Medical Retina
Avastin
Eylea
Lucentis
Ozurdex
Vabysmo
Diabetic Eye Laser Treatment
Laser Demarcation
Refractive Surgery
SMILE
LASIK
Photorefractive Keratectomy
SMILE
SMILE Self-Test
Patient Education
Patient Education
Cataracts
Astigmatism
Macular Degeneration
Diabetic Eye Disease
Glaucoma
Uveitis
Floaters
Retinal Detachment
Vitreous Detachment
Macular Pucker
Blepharitis
Dry Eye
Fluorescein Angiography
Resources
Patient Portal
Alphaeon Credit
CareCredit
Documents and Forms
No Surprises Act
For Doctors
Podcast
Contact
Mountain View Eye Center Consultation Form
Online Consultation Form
For severely increased eye pressure or if you need your patient seen urgently (within 72 hours), please call our office directly at 907-328-2920.
Please submit one consultation request per patient either as an Online Consultation Request Form or via Fax.
Name
(Required)
First
Last
Patient Information
Date of Birth
(Required)
MM slash DD slash YYYY
Date of Exam
(Required)
MM slash DD slash YYYY
Phone
(Required)
Referring Doctor
Referring Doctor Name
(Required)
First
Last
Practice
(Required)
NPI
(Required)
Referring Doctor's Email
(Required)
(Only used for confirmation of form submission)
Referring Doctor's Phone
(Required)
Referring Doctor's Fax
Patient's insurance
Reason for Referral
Retina
Refractive
Yag Cap / PCO eval
Oculoplastics
Cornea
Glaucoma
ANA Evaluation
Dry Eye
Other
Cataract (order pre-operative testing including corneal topography & biometry)
Other
Team Preference
I have a Preferred Consulting Mountain View Physician Team
I have no team preference
Preferred Consulting Surgeons’ Physician Team
(Please indicate Surgeon name) We will do our best to match your preferred referral request, and is not a guarantee. Patients may be directed to an alternate referring provider/team member due to scheduling needs.
Clinical findings/areas of concern:
Reason for referral - Glaucoma
Glaucoma
Glaucoma Suspect
Narrow Angle
Has a matrix, humphrey or octopus visual field been performed in your office within the last six months?
Yes
No
Pretreatment and highest know pressures:OD
Pretreatment and highest know pressures:OS
Most recent IOP/range: OD
Most recent IOP/range: OS
Current glaucoma medications:
Pertinent history/risk factors/additional requests
Please Choose One
Consultation, second opinion: patient wishes to return to my office for glaucoma management.
Glaucoma consultation and management requested at NWES, comprehensive eye care at my office.
Pertinent history/risk factors/additional requests