To submit a referral, you have two options:
1) Download and complete the appropriate referral form PDF and fax back to (480) 653-8776.
2) Scroll down to the e-form below, fill it out, and click “Submit”.
If you are an Arizona-based Optometrist making a referral please use this form: Download Arizona OD Referral PDF
If you are an Arizona-based MD or Primary Care Physician making a referral please use this form: Download MD/PCP Referral PDF
If you are an out-of-state OD (outside of Arizona) making a referral please use this form: Download Out-of-State OD Referral PDF
Pay Bill
Refer a Patient
Patient Portal
