Refer Your Patients to Us

ReFocus Eye Health’s physicians benefit from a collaborative referral network designed to enhance the primary doctor-patient relationship. Our ophthalmological team draws from a deep reserve of interdisciplinary talent with a full range of cataract, cornea, glaucoma, pediatric, retina, and oculoplastic specialists. We are committed to providing referred patients with specialized services so that the primary physician may resume their expert care whenever clinically feasible.

Please fill out the form below to request a referral. You can also fax your referral requests to 844-512-2422.
For Manchester, CT referrals, please fax to 860-643-4901

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

Location Requested *

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