Patient Referral Form

Over 2,000 doctors from around the world refer their patients to Retina Consultants of Texas. We love what we do, and look forward to providing you and your patients with exceptional care and support. Please use the referral form below to get started.

For any eye related emergencies, please call us IMMEDIATELY at 800-833-5921 (Houston) or 210-903-1046 (San Antonio). A physician is on call 24/7, including weekends and holidays.

Patient Referral Form

Name of Patient *

Which location is most convenient for your patient? *

Rendering Physician at RCTX

Patient DOB *

Patient Phone *

Enter a number with at least 10 digits and containing only numeric characters.

Patient Language *

Brief Description of Referral *

Name of Referring Doctor *

Practice Name *

Doctor Cell *

Enter a number with at least 10 digits and containing only numeric characters.

Office Phone *

Enter a number with at least 10 digits and containing only numeric characters.

Doctor Fax *

Enter a number with at least 10 digits and containing only numeric characters.

Doctor Email *

Upload medical records/images/demographics/insurance

Is this your first referral to Retina Consultants of Texas? *

Yes

Do you need referral materials and/or brochures? *

Yes

Notify me about upcoming CE events at RCTX! *

Yes

Are you interested in registering for the RCTX Image Portal? *

Yes

Are you interested in discussing research and clinical trial opportunities?

Yes

Please leave this field blank.

Urgent Requests

For urgent requests, please call 713-524-3434

Insurance Plans

We accept all major insurance plans

PDF Referral Forms

If you prefer, you can download a form and fax it over.

PDF Referral Form

Dr. Patrick Staropoli Takes Temporary Leave to Pursue NASCAR Championship

We're thrilled to support Dr. Patrick Staropoli as he competes in this year’s NASCAR O’Reilly Auto Parts Series. His last day at the clinic is January 16, with a plan to return in November 2026. Our physician partners will continue to provide world-class retinal care to Dr. Staropoli’s patients during his absence.

Learn more about Dr. Staropoli’s temporary leave.

Dr. Patrick Staropoli Takes Temporary Leave to Pursue NASCAR Championship

Learn more about Dr. Staropoli’s temporary leave.

Thank you for trusting RCTX.

Patient Referral Form