Refer a Patient

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Patient Referral

Thank you for your referral partnership! To refer a patient use our ONLINE FORM or fax to 303-261-1601 using your EHR cover sheet or download and complete our PDF referral intake form below.

Ways to Submit a Referral:

Important Referral Reminders:

• Urgent referrals (need to be seen within 48-hours)- Call us ASAP at 303-261-1600 and follow provider prompts
• With all referrals, please include: patient phone number, exam notes, imaging, and demographics
• Referrals are processed Monday–Friday, 8:00 AM to 4:00 PM MT, within 2 business days
• We will contact your patients directly to schedule
• Patients can also online self-schedule HERE or directly on our website homepage for quicker processing and ease

For questions or concerns regarding referrals, please email: referrals@retinacolorado.com

asterik (*) denotes mandatory fields

• Provider 1

  First Name *

  Last Name *

  NPI *

  Email *

• Provider 2

  First Name *

  Last Name *

  NPI *

  Email *

• Provider 3

  First Name *

  Last Name *

  NPI *

  Email *

• Provider 4

  First Name *

  Last Name *

  NPI *

  Email *

• Provider 5

  First Name *

  Last Name *

  NPI *

  Email *

• Provider 6

  First Name *

  Last Name *

  NPI *

  Email *

Practice Info

Practice Name *

Phone *

Fax *

Practice Address *

City *

State *

ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP *

Recaptcha

SubmitPlease leave this field blank.

Additional Forms

Medical Records Release Form

Your patient or their legal representative must fill out our Medical Records Release form authorizing the release of their medical information. Once complete, fax to (303) 261-1601 or email to: MEDICAL RECORDS. Please allow 5-7 business days for processing.

Medical Release Form

Stroke Evaluation Referral Form

Early detection of Retinal Artery Occlusion (BRAO or CRAO) or Transient Monocular Vision Loss (TMVL) requires immediate evaluation and transfer to a stroke center to avoid subsequent clinical strokes and decrease chance of long-term disability. Our stroke eval referral form template is meant to assist you and your patients in the referral process when you spot symptoms suggestive of stroke. In addition, the form lists all recommended Denver Metro Comprehensive Level 1 Stroke Centers (CSC) who offer the full spectrum of neuroendovascular therapy.

Stroke Eval Form