Retinal Specialist Referrals in Connecticut

If this is a same day or urgent request please call
860 – 646 – 7704

Referring Physician Name: *

Office Phone Number: *

Office FAX number: *

Patient FIRST Name *

Patient LAST Name *

DOB *

Patient Phone Number *

Reason for referral *

Our physicians will send a follow-up consultation note to the FAX number provided unless otherwise instructed. Please contact us if you do not receive a follow-up note regarding the care of your patient.

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For Referring Doctors

We are happy to assist in seeing your patients at any of our locations as soon as possible. You may also call or fax us a request at the numbers listed below.

For FAX please utilize the referral form here:

Referral Form

(860) 646-7704

FAX #: 860-647-7340

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