{"id":2246,"date":"2025-05-08T22:32:45","date_gmt":"2025-05-08T19:32:45","guid":{"rendered":"https:\/\/oomc.com\/canj\/?page_id=2246"},"modified":"2025-05-08T22:46:10","modified_gmt":"2025-05-08T19:46:10","slug":"physician-referral","status":"publish","type":"page","link":"https:\/\/oomc.com\/canj\/physician-referral\/","title":{"rendered":"Physician Referral"},"content":{"rendered":"<style>\n.inner h1 {margin:0px auto; color:white; font-family: 'museo-slab', Arial, sans-serif; font-weight: 800; font-size: 4.5rem; line-height: 88px; margin: 0 auto 35px; transition: all .3s ease; padding: 75px 70px; max-width:1800px; box-sizing: border-box;}\n<\/style>\n<div class=\"form-page form-page\">\n<div class=\"clearfix\"><\/div>\n<section class=\"section-about-doctors section-evo-see-the-world\">\n<div class=\"content-wrapper\">\n<div class=\"section-text\">\n<p style=\"color: #363636;\">We provide the same exceptional care that you do to give your patient\u2019s a brighter future.<\/p>\n<\/div>\n<div class=\"section-about-doctor-right\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2245-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2245\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/canj\/wp-json\/wp\/v2\/pages\/2246#wpcf7-f2245-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"2245\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2245-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:2245,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;referral_group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;other_referral_type&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;referral_group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;referral_type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;other-referral-show&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;referral_type&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h2 style=\"color:#795AC0;font-size:36px;font-family: 'museo-slab', Arial, sans-serif;font-weight:900;text-align:center; margin-bottom:35px;\">Patient Referral Form\n<\/h2>\n<div class=\"partners-form-item full\">\n\t<p><span style=\"display: block;\">Referring Practice Name:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"practice_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Practice Name\" value=\"\" type=\"text\" name=\"practice_name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full\">\n\t<p><span style=\"display: block;\">Referring Provider Name:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referral_provider\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Referring Provider Name\" value=\"\" type=\"text\" name=\"referral_provider\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full\">\n\t<p><span style=\"display: block;\">Referring Practice Email:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"practice_email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Practice Email\" value=\"\" type=\"email\" name=\"practice_email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full\">\n\t<p><span style=\"display: block;\">Referring Practice Phone Number:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"practice_phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Practice Phone Number\" value=\"\" type=\"tel\" name=\"practice_phone\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full two-input\">\n\t<p><span style=\"display: block; width:100% !important;\">Patient Full Name:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"first_name\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"last_name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full\">\n\t<p><span style=\"display: block;\">Patient Phone Number:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient Phone Number\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full\">\n\t<p><span style=\"display: block;\">Patient Email (Optional):<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient_email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Patient Email\" value=\"\" type=\"email\" name=\"patient_email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full\" id=\"preferred-location-title\">\n\t<p><span>Preferred Location<\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full preferred-location-group\" style=\"margin-bottom:25px;\">\n\t<p><select name=\"preferred-location\" id=\"preferred-location\">\n <option value=\"\">Select a Location<\/option>\n <option value=\"Not Specified\">Not Specified<\/option>\n <option value=\"Corneal Associates of New Jersey\">Corneal Associates of New Jersey<\/option>\n <\/select>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full\" id=\"preferred-provider-title\">\n\t<p><span>Preferred Provider<\/span>\n\t<\/p>\n<\/div>\n<div class=\"partners-form-item full preferred-provider-group\" style=\"margin-bottom:25px;\">\n\t<p><select name=\"preferred-provider\" id=\"preferred-provider\">\n <option value=\"\">Select a Provider<\/option>\n <option value=\"First Available Provider\">First Available Provider<\/option>\n\n <option value=\"Eli Moses, MD\">Eli Moses, MD<\/option>\n <option value=\"Sana Qureshi, MD\">Sana Qureshi, MD<\/option>\n <\/select>\n\t<\/p>\n<\/div>\n<div data-id=\"referral_group\" data-orig_data_id=\"referral_group\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<div class=\"partners-form-item full checkbox\">\n\t\t<p><span>Referral Type (Check One)<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referral_type\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"Retina\" \/><span class=\"wpcf7-list-item-label\">Retina<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"Glaucoma\" \/><span class=\"wpcf7-list-item-label\">Glaucoma<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"LASIK \/ Refractive\" \/><span class=\"wpcf7-list-item-label\">LASIK \/ Refractive<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"Oculoplastics\" \/><span class=\"wpcf7-list-item-label\">Oculoplastics<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"Neuro\" \/><span class=\"wpcf7-list-item-label\">Neuro<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"Pediatric\" \/><span class=\"wpcf7-list-item-label\">Pediatric<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"Cataract\" \/><span class=\"wpcf7-list-item-label\">Cataract<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"referral_type[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"other-referral-show\" data-orig_data_id=\"other-referral-show\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<div class=\"partners-form-item full\">\n\t\t<p><span>If selecting Other, please list the referral type<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other_referral_type\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other_referral_type\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr \/>\n<div class=\"clearfix\">\n<\/div>\n<div class=\"partners-form-item-button\">\n\t<p><button type=\"submit\" class=\"section-button section-button-small\">Submit<\/button>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n<div class=\"clearfix\"><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>We provide the same exceptional care that you do to give your patient\u2019s a brighter future.<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-2246","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Physician Referral - LASIK Essex County - Corneal Associates of New Jersey<\/title>\n<meta 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