Low Vision Rehabilitation Services
Patient Referral Form

Low Vision Optometrist
Occupational Therapist evaluation and treatment
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 *
Corrected Near Acuity
Current Prescription
Near Add
Is visual field reduced to 20” or less? *
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.
Additional Information

Insurance Information:

Primary *
Doctor type
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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