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Referring Doctors

Home
About
- Pricing
Services
Photo Gallery
FAQ
Contact
Schedule
Referring Doctors

WELCOME DOCTOR

Thank you for trusting Le Eye Spa with your patient referrals. Please complete the attached form, and our team will promptly follow up with your patient.

black blue and yellow textile

black blue and yellow textile

Patient Name*

Patient Date of Birth*

Patient Phone Number

Patient Email *

Patient Address

Referring Doctor Name*

Referring Doctor Phone Number*

Referring Doctor Office Email

Referring Doctor Office Fax

Reason for Referral & Service Requested (Check all that apply)

Dry Eye Disease

Meibomian Gland Dysfunction

Ocular Rosacea

Chalazion or Hordeolum

Blepharitis

Intense Pulsed Light (IPL)

Radiofrequency (RF)

Low level light therapy (LLLT)

Microblepharoexfoliation

Ocular irrigation (Rinsada)

Maintenance eye & lid hygiene

Other Notes

Email address

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Hours

By Appointment Only

Monday - Friday

Contact

9260 West Sunset Rd Ste 209, Las Vegas, NV 89148

info@leeyespa.com | (702) 518-2711*

*For fastest response times, please text or email

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