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Refer to Athens Clinic

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Please email referral notes to PThomas@georgiaeyeclinic.com

Referring Doctor(Required)

Date(Required)

MM slash DD slash YYYY

Contact at Referring Office(Required)

Phone(Required)

Patient Name(Required)

Birthdate(Required)

MM slash DD slash YYYY

Contact Number(Required)

Patient Email

Patient Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reason for Referral(Required)

Blurry or Decreased Vision

Cataracts

Diabetes

Dry Eyes/Allergies

Eye Pain

Glaucoma

Irritation/Discomfort

Macular Degeneration

Surgical Evaluation

Visual Disturbance

Retina Evaluation

Uveitis

Other

Urgency(Required)

Routine

Medically Urgent

Primary Insurance

Policy Number

Secondary Insurance

Policy Number

Choose a Clinic Location(Required)

Athens

Loganville

Greensboro

Athens Doctors(Required)

Centrael Evans, M.D.

Stephanie K. Lynch, M.D.

Tirth J. Shah, M.D.

Sejal Patel, O.D.

Please choose who the referral is for.

Loganville Doctors(Required)

Tirth J. Shah, M.D.

Sejal Patel, O.D.

Please choose who the referral is for.

Greensboro Doctors(Required)

Centrael Evans, M.D.

Tirth J. Shah, M.D.

Please choose who the referral is for.

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Office Hours

Mon – Fri 7:30am-4:30pm

Contact

Ph 706.546.0170
Fax 706.546.5015

Athens

1620 Prince Ave
Athens,GA 30606
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Greensboro/Lake Oconee

1030 Founders Row
Greensboro, GA 30642
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Commerce

Commerce Family Eyecare
1871 N Elm Street
Commerce, GA 30529
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Loganville

367 Athens Hwy
Suite 1750
Loganville, GA 30052
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Services

Cataract Surgery | Family Medical Eye Care | Glaucoma Treatment | Treatment of Macular Degeneration | Complete Diabetic Eye Care | Eyelid Surgery

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