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 *
Home Phone
Cell Phone *
Corrected Distance Acuity *
Current distance prescription OD
Current distance prescription OS
Near Add
Diagnosis *
ICD-10 Code *
I certify that the name above is legally blind
Date of last exam *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ocular history/add'l info

Insurance Information:

Primary *
Secondary
Dr. first name *
Dr. last name *
Dr. street *
Dr. city *
Dr. state *
Dr. zip *
Dr. phone *
Dr. fax *
Group/Affiliation Name
Dr. email

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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