Consultation Request Form

Please fill out the form below if you are referring a patient to our practice. We will contact the referring doctor by 5:00pm the next business day..

For emergency or time sensitive appointments, please call us direct at 913-261-2020 or toll free at 1-800-742-0020.

* Required
Patient Information
*First Name: *Last Name:
*Date of Birth (MM/DD/YYYY): / / *Home Phone:
*Primary Insurance:

Referring Doctor Information
*First Name: *Last Name:
*Telephone:
Email:

Appointment Information
Office Location:
Doctor's Name:
Preferred Appointment Date:
Appointment date must be at least 1 week from today. We will do our best to match the date/time to accommodate your request.
Preferred Appointment Time:
Reason for Consultation:
*Type password shown below:
The Captcha image
Schedule an Appointment

Meet Our Doctors

Contact Us



Our website is not intended to replace the services of a trained ophthalmologist.
Please consult a physician in all matters relating to your health.

Copyright © 2005 Sabates Eye Centers. All Right Reserved.