wmeyecare - Referral Form

Referral Form
Thank you for your referral to West Michigan Eyecare Associates.

We provide comprehensive eye health and vision care in our Grand Rapids office. If you have any questions please call us at 616-949-8500, or email yourteam@wmeyecare.com.

Address: 2112 East Paris Ave SE. Grand Rapids, MI 49546
Office Hours:
Monday & Tuesday, 9:00am - 6:00pm
Wednesday, 9:00am - 5:00pm
Thursday. 7:30am - 4:00pm
Friday, 9:00am - 4:00pm
What service is the referral for?*

Low Vision ServicesDiabetic Eye CareVision TherapyComprehensive Eye examDry Eye EvaluationOther
Additional notes:
When does the patient need to be seen?*

Urgent (within one week)Within 1 week2-6 weeksFirst available appointmentWithin 6 months
Patient Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Medical Insurance
Phone Number
Please fax pertinent records to 616-949-2878 or email securely to yourteam@wmeyecare.com
Has the patient been informed of this referral?

YesNoNot sure
Please indicate any special needs of the patient:*

Wheelchair userDeaf or hard of hearingBlind or visually impairedNone known
Referring Provider Information
Doctor

First NameLast Name
Office Name
Office Phone
Office Fax
Should be Empty:

Referral Form