Refer a Patient to Texas State Optical - Midlothian

We work closely with local healthcare providers to support patients who require specialty eye care, medical eye evaluations, advanced contact lens services, and ongoing management of eye diseases. Complete the referral form below, and our team will coordinate care promptly while keeping you informed throughout the process.

Book Appointment

(972) 474-8591

An elderly male doctor in a white coat sits beside a female patient in a blue sweater as they converse while the doctor holds a pen and paper in front of an ophthalmoscope machine

Patient Referral Form

Thanks for contacting us! We will get in touch with you shortly.

Office Name

Physician Name *

Office Phone Number *

Office Fax Number *

Office E-Mail *

Contact Person Name *

Patient Details

Name *

First

Last

Date of Birth *

Day

Month

Year

Email Address *

Medical Insurance

Vision Insurance

Appointment Type *

Reason For Referral

I agree to receive referral follow-up communications from Texas State Optical Mansfield. *

Yes

Upload Records or Diagnostic Reports ( Optional )

All patient information submitted through this form is encrypted and HIPAA-compliant. We will never share patient data without consent.

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