REFERRAL FORM
This form is for your convenience to expedite referral for vision services of any type. You can bookmark this page or save it on your destop, and with a single click, come here to initiate a referral. By clicking submit, an e-mail will be sent to our scheduling coordinators, who will call you within a few minutes. This saves you the time to call and prevents any time on hold. Please be mindful of privacy and HIPAA concerns as this is a nonencrypted e-mail. Please include only basic information such as type of problem and timeframe of desired referral. We will establish private patient data when we call, thus protecting patient privacy.

If this is a true emergency, or if you just prefer to call, the direct referral number is 419.578.7545.