A smiling nurse with her hand on a patient's sholder.

Doctor's Portal Referral Form

We're excited to have you visit! This is the Patient Referral Form for doctors sending patients to us for care. This simple form will help us coordinate the care of your patients between our offices. After filling out the form please wait for a submission confirmation. If you have questions about the form, please click the audio player below or call our office at 229.800.4712 for assistance.

PORTAL INSTRUCTIONS

Patient's First name

Please provide the patient's first name.

Patient's Last name

Please provide the patient's last name.

Patient's Birthday

Month

Day

Year

Patient's Email

Please provide the patient's preferred contact email address.

Patient's Phone

Please provide the patient's preferred contact phone number.

Referring Practice/Doctor name

Please provide the practice and referring doctor's name for coordination of care.

Address

Please provide the practice address to send our consultation report.

Provider's Phone Number

Please provide the provider's preferred contact phone number.

File upload

Please upload encrypted/password protected documents only.

I am referring my patient for:

Diagnostic testing only.

Diagnosis confirmation/consultation (Diagnostic 2nd opinion).

Treatment/fitting and please return for annual primary care. (most common).

Treatment/fitting and continued comprehensive eyecare of patient. (uncommon)

37 Calumet Pkwy Bldg. G.

Suite 101

Newnan, GA 30263

Phone

229-800-4712

Doctor's Portal Referral Form

Atlanta Cornea Care Center Dr. Kenyatta Brantley, Optometrist (P.C.)

Atlanta Cornea Care Center
Dr. Kenyatta Brantley,
Optometrist (P.C.)