Provider Referrals

This form is to be completed by a referral source only. If this is a SAME DAY referral or an EMERGENCY referral please do not use this online referral form, but call the office directly to make your referral. Please note that Dr. Michael Hopen will prioritize severe or surgical glaucoma cases with other suspect or less severe cases, a doctor may be assigned under the leadership of Dr. Hopen.

Referral Fax Number: 317.297.6503
Referral Phone Number: 317.846.4223 ext. 192
Glaucoma Referral Fax Number: 317.245.4620

Preferred Office LocationCarmel (1320 City Center Drive, Suite 150)
Indianapolis (3850 Shore Drive)

Name of Referring Medical Practice:

Name of Referring Doctor:

Practice Phone

Practice Fax

Patient Information

First Name

Last Name

Date Of Birth

Patient Email

Patient Phone

**Email is/can be used ONLY to communicate with patient regarding appointment days/times.**

Patient Address

Do you have medical or vision insurance?Yes
No

Reason For ConsultationNew Issue
Old Issue

History/Note/or Additional Comments

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