Everyday Eye Care

Medical Expertise, Everyday Clarity.

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Schedule Appointment

For Referring Providers

Please use the form below to refer a patient to our practice.

Patient Referral Form

Complete the form below to refer your patient. All fields are required unless otherwise stated.

Select a Location

Pasco

Sunnyside

Referring Provider Information

Your Name

Practice Name

Phone Number

Email Address

Fax Number (Optional)

Patient Information

Patient's Full Name

Patient's Date of Birth

Patient's Phone Number

Reason for Referral

Diabetic Eye Exam

Glaucoma Evaluation

Cataract Evaluation

Macular Degeneration

Dry Eye Evaluation

Red Eye / Infection

Flashes / Floaters

Other

Exam Type Requested

Comprehensive Eye Exam

Contact Lens Exam

Medical Eye Evaluation

Specialty Contact Lens Eval (Scleral, RGP)

Additional Comments or Information

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