P: (303) 772-3300 | F: (303) 682-3380 | M-F 7:30am – 5:30pm

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Patient Referral Form

Direct Referral Line for Front Range Eye Health Center: 720-684-4332

Existing Patient Inquiry

New Patient Inquiry

BOULDER

3000 Center Green Drive
Suite 250
Boulder, CO 80301
*No Well Eye Exams or Optical Department

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

LAFAYETTE

300 Exempla Circle
Suite 120
Lafayette, CO 80026
(Located within Exempla Community Physicians Pavilion)

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

LONGMONT

1400 Dry Creek Drive
Longmont, CO 80503

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

GREELEY

1616 15th Street
Greeley, CO 80634
(Located within Welch Eye Clinic)
*No Well Eye Exams or Optical Department

Call: (303) 772-3300
Text: (720) 806-9330
Fax: (303) 682-3380

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Are you experiencing?
- Clouded, blurred, or dim vision?
- Difficulty seeing distant objects?
- Sensitivity to light or glare?
- Difficulty seeing distant objects?
- Seeing a halo around lights?
- Fading or yellowing of colors?
Has your prescription for eyeglasses changed more often than usual?
- Yes
- No
Do you need brighter light for reading?
- Yes
- No
Does your vision sometimes seem distorted?
- Yes
- No
Have you experienced double vision in one eye only?
- Yes
- No
Do you see “ghost” images?
- Yes
- No
How do you prefer to have a member of our clinic’s staff follow up and contact you?
- Phone
- Email

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