Referral Form

At Redmond Eye Clinic, we provide the highest quality service to all our patients. In order to refer a patient, please fax over the last completed doctor's note to the office at 425.881.0230 and use the form below to request the appointment. Please note that we will reach out to the patient to schedule. You may also call us to request an appointment. Thank you!

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Please include the full referring provider name.
Please include the referring provider office name.
Please include the referring provider office phone number and/or direct email address.
Please describe why you are referring your patient to Redmond Eye Clinic.

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First & Last Name
MM/DD/YYYY
Street Address, City, State, Zip

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Insurance Company & Policy ID #

Referral Form

At Redmond Eye Clinic, we provide the highest quality service to all our patients. In order to refer a patient, please fax over the last completed doctor's note to the office at 425.881.0230 and use the form below to request the appointment. Please note that we will reach out to the patient to schedule. You may also call us to request an appointment. Thank you!

Section Break

Please include the full referring provider name.
Please include the referring provider office name.
Please include the referring provider office phone number and/or direct email address.
Please describe why you are referring your patient to Redmond Eye Clinic.

Section Break

First & Last Name
MM/DD/YYYY
Street Address, City, State, Zip

Section Break

Insurance Company & Policy ID #