For Healthcare Providers

Referral Request

Refer your patient to Dr. Shashi D. Ganti, MD FASRS — fellowship-trained Vitreo-Retina & Cornea specialist in Fremont, CA.

Urgent / Emergent Referrals

For same-day or urgent referrals, please call our office directly at (510) 556-2153 or fax to (510) 556-2155. Do not rely solely on this form for time-sensitive cases.

Referring Provider Information

Referring Provider Name*

Practice / Clinic Name*

Office Phone*

Office Fax

Email Address

Patient Information

First Name*

Last Name*

Date of Birth*

Patient Phone*

Insurance Provider

Insurance Member ID

Clinical Details

Reason for Referral*

Urgency*

Routine

Within 2–4 weeks

Urgent

Within 1 week

Emergent

Same day / ASAP

Clinical Notes / Additional Information

By submitting this form you confirm you have patient authorization to share this information. For HIPAA-compliant transmission, you may also fax records to (510) 556-2155.