Welcome to the referral portal for Lumen Optometric + Treehouse Eyes.

Please fill out all the pertinent information for either an initial referral or for the six-month follow-up. Thank you!

Required Information


Required Information
MUST SPECIFY Referral OR F/U:
Referring Doctor's Name
Referring Doctor's Phone #
Referring Doctor's Office Name
Patient's Name
Patient's DOB (mm/dd/yyyy)
Patient's Phone #
Will you be comanaging?


Before you click submit, please click through to the "Initial Referral" or "6 Month Follow-Up" tabs at the top to fill in the corresponding data.

Initial Referral


Initial Referral
Reason for Referral:
OD Subjective Rx: DVA 20/
OS Subjective Rx: DVA 20/
OD Habitual Rx: DVA 20/
OS Habitual Rx: DVA 20/

Are there any pertinent details you would like us to know?  

Are there any specialty care patients you would like for us to send your way?  


Please kindly ask your patient to save our number:

(626) 921-0199 as:
"Lumen Referral Doctor"

And please instruct them that they will be receiving a text and an email
to schedule a complimentary consultation.

*Once we initiate treatment, we will send a post-treatment report and the patient will be sent back
to you for ongoing comprehensive care, while we only manage the specialty care.

6 Month Follow-Up


Referral Information
What is the treatment?:
Entering OD DVA 20/
Entering OS DVA 20/
OD Subjective Rx: DVA 20/
OS Subjective Rx: DVA 20/
OD Anterior Health:
OS Anterior Health:

Are there any pertinent details you would like us to know?   


Thank you for your comanaged care! At this point, please pre-appoint your patient for their annual comprehensive examination at your office.

Patients are encouraged to order backup glasses at your office for nights when they do not have the opportunity to sleep in the lenses.

A -1.00DS Rx will suffice.