Refer a Patient

Patient Referral Information and Form

Fill out the form below with your referrals.

Referring Doctor’s Name

Referring Doctor Email

Phone Number for Referring Doctor's Office

Referring Doctor’s Office Fax Number

Patient’s Full Name

Patient’s Phone Number

Patient’s Email

Reason for Referral / Comments

Would you like the patient sent back to you for primary care exams?

Yes No

Important Note: Please fax any relevant exam notes, corneal topography, and records to (919) 701-4641.

Our Doctors Lecturing at a Recent Conference