Physician Referral Form

To refer a patient to Florida Eye Microsurgical Institute, please fill out the online form below. If you’d prefer, you can download the “Referral Form for Surgical/Medical Consultation” and fax us a hardcopy printed form to (561) 737-7055. Also, if you would like to save your work to return and finish later, you can do so by clicking the link for this you’ll find next to the “Submit” button. After submitting this form, you will be emailed a copy of what you entered (for your records).