Call 410-224-6680 or 301-565-1651
Patient Portal
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Need Immediate Attention?

We are available 24 hours a day, 7 days a week.

Call Us: 

410-224-6680 or 301-565-1651

Referral Form

* Patient First Name
* Patient Last Name
* Patient Phone Number
Email Address
* Referring Doctor
* Date
* I am referring my patient for care. Please evaluate the following problem(s) or condition(s):

Important Notes:

  • If afterhours, weekends, or holidays please call for an emergency visit.
  • Please call to follow up for same day and next day visits, after submitting referral.
* Please have the patient scheduled:

Click here for locations and contact information. See the table below for the locations where each physician is available.

Preferred Physician (optional)
Preferred Location (optional)

* Please check the method(s) of communication you prefer:

Fax Number (not required unless multiple locations):

Retina Associates and its doctors and staff do not have a consultative, advisory or other financial arrangement with any of the companies that manufacture or distribute the treatments prescribed to Retina Associates’ patients. We believe that patients and referring doctors have a right to full disclosure regarding financial relationships.