Refer a Patient

Dr. Edward Washington and the staff of Peachtree Ophthalmology would be pleased to take care of your patient's eye care needs.

For your convenience, we offer two options for referring a patient.

1. Please print and complete the Consult Request Form below and fax to our office at 770-609-8356.
   Consult Request Form
2. Please complete and submit the Online Consult Request Form below.
Patient Information

Patient Name:
Patient Date of Birth:
Patient's Home Phone:
Patient's Cell Phone:
Patient's Work Phone:
Primary Insurance:
Secondary Insurance:
Referral for:
Please choose all that apply:	Cataract Glaucoma Diabetic Exam Visual Field OCT Consultation
History:

Office Information

Referred By:
Street Address:
City:
State:
Zip:
Phone:
Email Address: