Refer a Patient

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 (704) 703-8051.

Our Doctors Lecturing at a Recent Conference