Consultation Request

This form is specifically for use by providers from other offices requesting a patient consultation with one of our providers. It is not for patient use.

* Required Field

Please provide the following contact information:

Contact Information

Patient Name*
Date of Birth*
Vision Number*
Requesting Provider*
Office Name*
Reason for Consult*
Referral Needed* Yes    No
If Yes, Referral Contact*
Consultation Needed* Within 2 Weeks    Next Available

Providers Available
Select All Applicable
Robert A. Tribuzio, M.D.
James E. Spicher, M.D.
Larien G. Bieber, M.D.
Samuel A. Rice, M.D.
Stephanie Todd, M.D.
No Preference

Your e-mail will be received by our referral staff. Paula will call and schedule the appointment with the patient. Please fax all pertinent studies and progress records to Paula at 397-7634.


Your Full Name*
Your Phone Number*

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2301 Columbia Avenue Lancaster, PA 17603
Phone - 717.397.2738 Fax - 717.397.7634

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