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Department of Ophthalmology
Harvey & Bernice Jones Eye Institute
4301 W Markham St. #523-3
Little Rock, AR 72205
501-686-5822 (phone) 501-526-6780 (fax)
www.eye.uams.edu
REFERRAL FORM
If this is an emergency and your patient needs to be seen immediately, please call 501-686-5822
Patient Name: PLEASE PRINT____________________________________________________________________
Patient Phone #:_________________________ Patient DOB:___________________________________________
Address:_____________________________________ Insurance: ________________________________________
Reason for Referral:_____________________________________________________________________________
Urgency: Within 24 hrs:______________48 hrs:_____________ 1 week: _____________Routine:_______________
Referring Physician Name:________________________________________________________________________
Referring Physician Office #:___________________________ Fax #:______________________________________
Referring Physician Email:________________________________________________________________________
Special Instructions (specify if specific doctor is requested, otherwise our staff will determine the appropriate
specialist):_____________________________________________________________________________________
Adult Strabismus
Brita S. Deacon, M.D.
R. Scott Lowery, M.D.
Paul H. Phillips, M.D.
Glaucoma
R. Grant Morshedi, M.D.
Low Vision
Richard A. Harper, M.D.
Anna Schlesselman, O.D.
Cataract & Comprehensive
Romona Davis, M.D.
Richard A. Harper, M.D.
David B. Warner, M.D.
Neuro-ophthalmology
Joseph G. Chacko, M.D.
Paul H. Phillips, M.D.
Comprehensive
Thomas Cannon, M.D.
David T. Nixon, M.D.
Oculoplastics and Orbit
John D. Pemberton, D.O.
Christopher T. Westfall, M.D.
Cornea & External Disease
David B. Warner, M.D.
Optometry
Kathryn L. Brown, O.D.
Anna Schlesselman, O.D.
Pediatric Ophthalmology – ACH
501-364-1150
Brita S. Deacon, M.D.
R. Scott Lowery, M.D.
Paul H. Phillips, M.D.
Refractive
David B. Warner, M.D.
Retina
Sami Uwaydat, M.D.
Ocular Genetic Clinic referrals
Amanda Hilborn, RN III, BSN
Email: [email protected]
ERG Scheduling
Amanda Hilborn, RN III, BSN - ERG
technician
Email: [email protected]
UAMS CONFIDENTIALITY NOTICE
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is strictly prohibited. If you have received this communication in error, please notify the sender immediately. If you cannot reach the sender,
please contact the UAMS HIPPA Office at 501-603-1379.