For Referring Doctors

Referral Form

At Redmond Eye Clinic, we provide the highest quality service to all our patients. In order to refer a patient, please fax over the last completed doctor's note to the office at 425.881.0230 and use the form below to request the appointment. Please note that we will reach out to the patient to schedule. You may also call us to request an appointment. Thank you!

Section Break

Referring Provider Name(Required)

Please include the full referring provider name.

Referring Office(Required)

Please include the referring provider office name.

Referring Provider Office Contact Information(Required)

Please include the referring provider office phone number and/or direct email address.

Reason For Appointment(Required)

Please describe why you are referring your patient to Redmond Eye Clinic.

Section Break

Patient Contact Information(Required)

First & Last Name

Date of Birth(Required)

MM/DD/YYYY

Patient Gender & Preferred Pronouns(Required)

Patient Address(Required)

Street Address, City, State, Zip

Patient Phone Number(Required)

Patient Email Address(Required)

Section Break

Patient Insurance(Required)

Insurance Company & Policy ID #

Is The Patient The Policy Holder?(Required)

Referral Form

Section Break

Section Break

Section Break

Quick Contact