Referral Guide

The following guide lists the information we need to ensure a quick, seamless patient referral for a treatment of Glassia.

All referrals must include:
  • Order
  • Patient Demographics
  • Supporting Clinicals (Notes and Labs)
Order Information:
  • Provider name
  • NPI#
  • Address
  • Phone/Fax
  • Provider signature (or electronically authenticated signature)
Patient Demographics:
  • Patient name
  • Phone number
  • Address
  • Insurance information (primary and secondary if applicable)
Supporting Clinicals (Notes and Labs):

    Ready to make a referral?
    Download our Glassia order form.

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