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Referring Doctors

Please use this page to submit an online referral.  VRS staff will contact the patient within 1 business day.

Referring Doctor*

Referral Doctor Contact Number:

Patient Name*

Patient Contact Number*

Time Frame

Clinical Notes

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Please indicate if you will be sending any patient information or photography by email.

Please send any supporting information to virginiaretinaspecialists@gmail.com.  

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