Referral

Referral

Referred by Dr. (required)

Doctor's Email (required)

Patient Name (required)

Alberta Health Care # (required)

Phone Number (required)

Date (required)

Reason for Referral: (required)
Routine Eye ExamPediatric ExamDiabetic Health ExamOcular Emergency / Red EyeFlashes / FloatersHeadachesPlaquenil Work UpHearing Test

Note:

Edmonton & Leduc Locations

Please visit one of our locations in Edmonton, Alberta. Our friendly team of staff and doctors are happy to assist you.

Millwoods

5615 23 Avenue NW
Edmonton T6L 7B9
T. (780) 450-6700
F. (780) 441-9461

Oxford Park Landing

15158 127 Street NW
Edmonton T6V 0C5
T. (780) 705-8816
F. (780) 705-8856

Terwillegar

14217 23 Avenue NW
Edmonton T6R 3E7
T. (780) 432-4301
F. (780) 432-4460

Leduc

107 4809 43A Avenue
Leduc T9E 8J6
T. (780) 612-4556
F. (780) 612-4558

Grange

2500 Guardian Road NW
Edmonton T5T 1K8
T. (780) 447-5860
F. (780) 447-5862