Refer to Lumen.

This form submits to refer@lumen.vision, a HIPAA-compliant email address dedicated to referrals. You can fill out the form below, and we will contact your patient. Or, if you want to schedule an appointment for them, you can using our online scheduler, or call us at (701)-404-9096.

Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Patient's Medical Insurance

If the patient has no insurance, write "none."

Patient's Phone Number

(###)

###

####

Patient's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient's Email

Additional Notes for Dr. Ryan:

Include tentative diagnoses and any pertinent clinical information.

Provider Name/Office

Who is referring this patient?

Provider Fax or HIPAA-Compliant Email

How can we communicate results to you?