Physician Referral Form

Request for Consultation

Please complete this form and email/fax doctor's notes and referral authorization if needed.
  • (mm/dd/yyyy)
  • Reason for Consultation

    The physician requesting this opinion understands that the consulting physician may initiate treatment or perform medically necessary diagnostics for this patient. The consulting physician will send the requesting physician an opinion and plan of care.
  • Choose one from the drop-down menu.
  • Preferred Retina Physician