Referrals

Thank you for choosing to refer to Athens Retina Center. Our referrals are our partners and our customers. We are available to you and your patients to deliver the care needed. Our state-of-the-art clinic has been designed to deliver patient-focused services.

You can complete the referral form as a PDF and fax it to our office at 706-433-1745 or call our office at 706-543-3200 and press option 5.

Begin a referral with the form below:

"*" indicates required fields

Patient Demographics

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Alt. Phone

Medical Insurance Plan*

ID number*

Referring Doctor Information

Referring Doctor*

Contact Name*

Phone Number*

Fax*

Reason for referral*

Patients Current Vision*

Additional Documents*

Please attach any office or patient notes along with copies of the patient's insurance card (front and back)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Hidden

For Office Use Only

Hidden

Notes Recieved from Referring

Yes

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Appointment Scheduled with

Dr. Iyer

Dr. Copeland

Dr. Carrol

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Informed Referring About Appointment By

Phone

Fax

Hidden

On what date

Hidden

at what time

Hidden

Appointment Date

Hidden

Appointment Time

Hidden

Handled By ARC Employee

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This field is for validation purposes and should be left unchanged.

You can also complete the referral form as a PDF and fax it to our office at 706-433-1745 or call our office at 706-543-3200 and press option 5.

When contacting us to schedule your patients, please have the following information readily available:

Patient demographic information
Reason for visit
Any special needs that will require facilitation once the patient arrives
Patient insurance information, if available

We will work with your patient to complete the registration process and to schedule an appointment at the patient’s convenience.

Three Northeast Georgia Locations To Serve You

Athens, GA

Our Primary Location

Cornelia, GA

Satellite Office

Greensboro, GA

Satellite Office

What Our Patients Say

Thank you! Our visit and examination at Athens Retina was very calming and comfortable. Your staff is sweet and communicates well, all in a professional and competent manner.