Refer a Patient

Referrals will be processed during normal business hours. For emergent referrals and patients that need to be seen by a Retina Associates physician within 48 hours, do NOT fill out this form, instead call us ASAP at 212.604.9800.

Please select ‘Not Listed’ in the provider name dropdown if your practice is not listed.

Referring Provider Details

Is this an urgent/emergent referral or diagnosis that needs to be seen within 72 hours?

Reason for appointment

Referring Provider First Name

Referring Provider Last Name

Designation

Practice name

Practice address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Provider or practice email address

Enter Email Confirm Email

Office phone number

Practice fax number

Urgency

Patient Information

Name

First Last

Enter Email Confirm Email

Phone

Phone type

Date of birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please describe concern

O.D. (Right)

O.S. (Left)

O.U. (Both)

Diagnosis, symptoms, and notes for physician