Patient Referral

1428 W Hebron Parkway Ste 125, Carrollton TX 75010
P: 972.325.2022 E: info@focalpointec.com

Patient Referral Form
This portal is for providers who have patients that need Myopia Management services, specialty contact lenses, or dry eye treatment.

Thank you for your referral. We are honored to participate in the care of your patient.
Is this a new referral?
Please select one
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Phone contact for Patient*
Email contact for Patient*
What service are they being referred for?*

Myopia ManagementScleral LensesOrtho-KeratologyIPL/RFAxial Length Biometry OnlyOther
Patient Records

Please send a copy of the patient's most recent exam so the patient does not have to repeat their routine exam if they are being referred for specialty testing or treatment only.
Cancelof
Any comments regarding this patient that will help us improve their care?
For example, if the patient is a child, please include parent/guardian information
Referring Doctor Name
Practice Name and other information*
Please also include your office phone number and fax number so we can send reports and the patient back to you for their regular care.
Please verify that you are human*
Should be Empty: