Refer A Patient | Retina Consultants of Hamilton

Refer a Patient to Precision Retina Care (PRC) Clinical Service

Clinical care is provided by Dr. Varun Chaudhary through his Medical Professional Corporation.*

Name(Required)

Full Name

Phone(Required)

Fax(Required)

Email(Required)

Patient Name(Required)

First Last

Phone(Required)

Date(Required)

DOB(Required)

VA: O.D. 20/:(Required)

VA: O.S. 20/:(Required)

Research

INTERESTED IN RESEARCH

History & Diagnosis(Required)

Special Instructions

Testing Only (Please Specify)

Please Specify(Required)

Consent(Required)

I confirm that I am authorized to share this patient’s information for the purpose of this referral and consent to its secure transmission.

Prefer not to refer online? Download our fillable referral PDF form

905 573-4858