Referral Form

  • MM slash DD slash YYYY
  • Please provide us with your name or the name of the veterinarian whom Eyeshine Veterinary can update after we see this patient.
  • Name of veterinary hospital or clinic where you work or that provides primary care services for patient being referred.
    Please select appropriate species of your patient.
  • Please include all medications the patient has been prescribed for both ophthalmic and non-ophthalmic conditions.
  • Please provide us with any additional information we should know about your patient or this case.
  • If you have any additional questions or would like to speak with a member of the Eyeshine team - please do not hesitate to contact us at 1-888-EYE-VET-5 or send an email to

Arizona’s Only Independent Veterinary Ophthalmologist

(888) EYE-VET-5

(888) 393-8385