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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

Please provide the patient's first name.

Please provide the patient's last name.

Patient's Birthday
Month
Day
Year

Please provide the patient's preferred contact email address.

Please provide the patient's preferred contact phone number.

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

Please provide the practice address to send our consultation report.

Please provide the provider's preferred contact phone number.

Please upload encrypted/password protected documents only. Passcodes may be sent to info@atlantacorneacare.com

I am referring my patient for:

Contact Us

Address

37 Calumet Pkwy, Bldg. G

Suite 101

Newnan, GA 20363

Contact

229-800-4712

info@atlantacorneacare.com

Opening Hours

​Sunday

By Appointment Only

Mon - Wed

9:00 am – 4:00 pm

Saturday

By Appointment Only

The Atlanta Cornea Care Center

Irregular Cornea & Scleral Lens Clinic

37 Calumet Pkwy Bldg. G. 

Suite 101

Newnan, GA 30263

Phone

229-800-4712

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