Thank you for the trust you put in Alliance Vision Institute. This information will will be transferred to a staff member who will contact the patient in a timely manner. Alliance Vision Institute is committed to treating and using protected health information responsibly. In using this information, our office will comply with all state and federal laws pertaining to a patient’s privacy rights, including the Privacy and Security protections provided to the patient by HIPPA.

Please note: This form is for referring doctors and staff only.
If you are a patient, please call our office at 817-442-2020 or fill out our contact form here.

Please complete the form below to refer your patient to our office. Please provide the last visit note, current patient demographics and current medical insurance card to our office. If your patient has a Medical HMO Insurance, they will need an Insurance Referral from their Primary Care Provider to our office. Please advise all contact lens patients, they will need to discontinue wearing contacts for 1 week prior to their vision correction evaluation (i.e.: Cataract, LASIK, PRK, RLE or ICL exams).

Referral Network Link

  • MM slash DD slash YYYY
  • Max. file size: 50 MB.

Alliance vision
institute

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Monday : 8:00 AM – 5:00 PM
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Tuesday : 8:00 AM – 5:00 PM
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Wednesday : 8:00 AM – 5:00 PM
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Thursday : 8:00 AM – 5:00 PM
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Friday : 8:00 AM – 5:00 PM
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Saturday – Sunday: Closed