Referring Providers

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Referring Providers

Referral Form

To refer a patient for consultation, or surgery, please complete the online referral form linked below. If you need any assistance, please call our office during clinic hours.

Patient Information

Patient Name:

Home Phone #:

Alternate Phone #:

Date of Birth:

Email:

Preference of provider:

Reason for Referral

Reason for Referral:

Additional Information:

Location:

Other Information

Referring Provider:

Referring Provider Phone:

Referring Provider Fax:

Do you wish to co-manage this patient?

Yes No

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Continuing Education

IEC has received approval to offer CE classes for ODs from the Indiana Optometry Board. If you have interest in attending a class at the Indiana Eye Clinic, please email info@indianaeyeclinic.com.

Register Online

Please fill out the form below to register online.

Name

Practice Name

Street

City

State

Zip Code

Phone