Surgical Referral For Adults

Here at PBGA, we help connect our clients to local eye health care professionals. Please fill out this form entirely to the best of your ability. We do require  proof of income and a doctors note if you were not seen at a PBGA clinic.

Proof of income includes: 

  • Last year’s W2
  • Last 2 months of bank statements = 1 proof of income
  • 2 current paycheck stubs = 1 proof of income
  • Social Security Administration Award Letter.
  • Unemployment Claim/Wage Inquiry statement
  • ANY information regarding financial circumstances, including monthly amounts received on ANY other sources of income (ex: TANF, pension, retirement, child support, food stamps, part time employment, etc.)

Once we have received your completed form and documents, we will reach back out within 2 – 4 weeks.

Should you have any questions or issues when filling this form out, please email [email protected].

Surgical Referral Form


Weight approximation within 10 lbs is acceptable, but answer is required!

Special Questions




Please check if one of the following applies to you
If not, are you currently or possibly preganant?


Do you currently or have you ever had:

Current Medications (please complete all fields)

Allergies/Intolerances (please include details of reaction)

Surgical History

Anesthesia History

Have you or anyone in your family had an unusual reaction to anesthesia, such as


IMPORTANT: Include full names of your primary care provider as well as any specialists (cardiologist, pulmonologist, neurologist, endocrinologist); Failure to do so may result in delay of your surgery.
Max. file size: 10 MB.
Please upload these forms to verify your proof of income.
Max. file size: 10 MB.
If you were not seen at a PBGA clinic, please provide doctors note.