Patient Referral Form

Patient Name*

Patient DOB*

Patient Phone*

Referring Doctor Name*

Doctor’s Address*

Practice Contact Name*

Practice Contact Phone*

Preferred location:

Reason for Referral / Comments

Please use this link to upload patient medical records which are required for neuro-ophthalmology and cornea evaluations. This link will require additional fields to be completed.

Click Here to Upload Files

You may also FAX medical records to initiate scheduling.​ Please indicate in the Comments section if faxing records.

​​​​​​​Memorial | 1237 Campbell Rd, Houston, TX 77055 | Fax: 713.365.9356
Katy East | 23510 Kingsland Blvd, Ste 200, Katy, TX 77494 | Fax: 281.395.7004
Spring | 21848 Holzwarth Rd, Ste 200, Spring, TX 77388 | Fax: 346.351.2818

​​​​​​​Thank you for keeping record submissions secure and HIPAA compliant.
​​​​​​​