Refer to ReFocus Eye Health: Partnering for Exceptional Eye Care

At ReFocus Eye Health, we understand the trust you place in referring your patients. Our specialists excel in medical eye care, offering a comprehensive range of services from corneal treatments to retinal surgeries. We prioritize precision and patient comfort, ensuring each referral receives personalized attention and care. Together, let’s elevate the standard of eye care for your patients. Partner with our Trappe practice for a seamless, patient-focused experience that reflects the commitment to excellence you share.

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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