Refer a Patient

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Thank you for trusting The Retina Eye Center.

We love what we do, and look forward to providing you and your patients with exceptional care and support. If this is not a retina related emergency, please fill out the form below. For any retina related emergencies, please call us at (706) 481-9191.

Want to refer a patient online?

Use the form below to send your information, and the TREC team will respond promptly.

Refer Patient Online

We look forward to hearing from you!

asterisk (*) denotes mandatory fields

Patient Name *

Patient Date of Birth

Patient Phone

Patient Insurance

Patient Address

Brief Description of Referral

Select Preferred Doctor

Dr. Oksana Maria DemediukDr. Ranjit DhaliwalDr. Nitin Nigam

Name of Referring Doctor/Practice *

Doctor Phone *

Doctor Fax *

Doctor Email *

Is this your first referral to The Retina Eye Center? *

Yes

No

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Please be aware that The Client cannot ensure that communications sent over the Internet are secure. This includes correspondence sent through this form or by email. If you are uncomfortable with such risks, you may contact us by phone instead of using this form.

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