New Doctor Referral Form

Welcome to our General Referral Form

Please Use this form to refer someone to our services. If you are a Physician, you can use this form as your prescription for the iCare HOME. If you have additional patients we can customize your referral experience! Just click the box below to get a personal referral form.

Practice Name(Required)

Doctors First Name(Required)

Doctors Last Name(Required)

Doctors Contact Information(Required)

This will be used to send you the finalized report from your patients' data if you don't have a practice email.

Doctors Phone

Comment

By filling out this form, this will serve as your prescription for this device and we will dispense one of the following:(Required)

RENTAL/PURCHASE

Please select a rental period if applicable(Required)

Would you like us to send you some HOME patient brochures?

YES

Please enter your Mailing address for the brochures!(Required)

Street Address Address Line 2 City State ZIP Code

Would you like us to create your own quick referral button on the "Doctors" section on our website?(Required)

Yes!

Not at this time

Please enter your NPI or DEA license number(Required)

Doctor's OR Practice's Email Address(Required)

This will be used for official communication from MyEyes and where the patients HOME2 data will be sent.

Please enter your Patient's Date of Birth(Required)

Patients First Name(Required)

Patients Last Name(Required)

Patient's Email

Patients Phone(Required)

Patients Address

Comment

Phone

This field is for validation purposes and should be left unchanged.

520 N Main Street, Suite C
Heber City, Utah 84032

Email info@myeyes.net (Preferred contact method)

Toll-free 1-833-5MY-EYES
(833-569-3937)

**Due to Unusual High Call Volumes, we ask you to be patient. Typically we are able to respond within 24-48 Hours. If you need immediate help, please send us an email**

Hours of Operation: M-F MST 10am-4pm

Purchase an iCare® HOME2 today for as low as $106/mo. Pay over time with flexible financing options!

Welcome to our General Referral Form

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