Optimal Care: Partner with ReFocus Eye Health

At ReFocus Eye Health, we understand the trust and responsibility of patient referrals. We’re here to complement your care by providing specialized treatments for complex eye conditions. Our specialists deliver personalized attention and advanced solutions, ensuring the best possible patient outcomes. Trust us for a seamless continuum of care where your patients become our shared priority. Together, we can achieve optimal vision health for our community.

Please fill out the form below to request a referral. You can also fax your referral requests to 844-512-2422.

Patient Information

First Name *

Middle Name

Last Name *

Date of Birth *

Sex

Female Male

Phone Number *

Alternate Phone Number

Insurance Company

Policy Number

Referring Office Information

Doctor First Name *

Doctor Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Practice Name

Phone Number *

Fax Number

Please send a follow up with appointment info

Fax Email

Appointment Request *

Priority (3-4 days) Non-Urgent (1-4 weeks)

Notes for Appointment (please include diagnosis and reason for visit): *

All information is stored securely and is HIPAA compliant

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