Refer a Patient

Name of Referring Physician*
Referring Practice*
Provider Phone Number*
Provider Email
Name of Patient*
Date of Birth*
Patient's Phone Number*
Patient's Email
Choose a Physician for General, Cataract, Corneal, Refractive, & MIGS:
- Dr. Milan Patel (Cumming, Johns Creek, Canton)
- Dr. Niraj Desai (Cumming, Alpharetta)
- Dr. Samir Vira (Cumming, Marietta, Alpharetta)
- Dr. Cameron Johnson (Canton)
- Dr. Sagar Patel (Buford, Snellville)
- Dr. Aldo Espinoza (Canton)
- Dr. Rooshil Patel (Marietta, Canton)
- Dr. Logan DeHoff (Canton)
For Glaucoma and Cataracts:
- Dr. Niraj Nathan (Buford, Snellville)
For Reconstructive & Aesthetic Oculofacial Plastic Surgery
- Dr. Kiran Sajja (Cumming, Canton, Marietta, Alpharetta)
- Dr. Sagar Patel (Buford, Snellville)
Reason for Referral [NO GLASSES OR CONTACT LENS SERVICES]*
- LASIK/Refractive Evaluation
- Cataract Evaluation
- Corneal Evaluation
- Glaucoma/MIGS Evaluation
- Oculoplastic Evaluation
- If other, please list below.
Other reason for referral
Is this an urgent appointment?*
- Yes
- No
Please attached exam notes or testing below or fax them to 678-381-2015
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