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
Patient Name*
First Middle Last
Date of Birth*
Month
Day
Year
Sex*
- Female
- Male
Phone Number*
Alternate Phone Number
Insurance Company
Policy Number
Referring Office Information
Referring Doctor:*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Practice Name
Phone Number*
Fax Number
Email
Please send a follow up with appointment info:
- Fax
- Email
Appointment Request*
- Priority: 3-4 days
- Non-Urgent: 1-4 weeks
This field is hidden when viewing the form
Please attach chart notes from patient’s most recent visit.
Drop files here or

Max. file size: 31 MB.
Notes for Appointment (please include diagnosis and reason for visit):*
All information is stored securely and is HIPAA compliant
Location Requested:*
Comments
Phone
This field is for validation purposes and should be left unchanged.