Low Vision Rehabilitation Services
Patient Referral Form
Low Vision Optometrist
Vision Rehabilitation Program
Patient First Name *
Patient Last Name *
Street Address *
City *
State *
Zip Code *
Date of Birth *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E-mail Address
Contact phone 1 *
Contact phone 2
Corrected Distance Acuity OD *
Corrected Distance Acuity OS *
Current distance prescription OD
Current distance prescription OS
Near Add
Diagnosis *
ICD-10 Code
Date of last exam *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ocular history/add'l info

Referring doctor:
First name *
Last name *
Group/Affiliation Name
Street *
City *
State *
Zip *
Phone *
Fax *
Email

Insurance Information:
Primary *
Secondary

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Contact our Low Vision Clinic
 

Contact Our Low Vision Services

  • Contact our Low Vision Services staff to learn more about how they can help.
  • Schedule an appointment at our Low Vision Services, which includes an assessment.
  • You will be scheduled at one of our convenient locations. 
San Diego: 5922 El Cajon Boulevard, San Diego, CA 92115
Vista: 1385 Bonair Road, Vista, CA  92084
Low Vision Services:  619-255-9741
Email:  lvc@sdcb.org