Dry Eye Care Texas | Referring Doctors

Please complete online referral request or download/print/fax pdf version.

We will contact your patient to schedule their Comprehensive Dry Eye Evaluation.

"*" indicates required fields

Patient Name*

Date

Patient DOB

Patient Phone*

Primary Insurance Provider

Secondary Insurance Provider (if applicable)

Patient History or Concern

Referring Doctor Name*

Referring Doctor Practice Name

Referring Doctor Email

Referring Doctor Phone

Referring Doctor Fax

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Comments

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