Patient Referral Form Patient Name First Last DOB MM slash DD slash YYYY Address Street Address City ZIP / Postal Code PhoneContact (in case of emergency) Insurance NO YES Diagnoses Associated with Vision Loss or Scleral/Specialty Contact Lens:Best Corrected Visual Acuity: OD OS Scleral or Specialty Lens goals:*Include Topo and/or OCTReduction in Visual Field? Yes No If yes, please send the last VFPlease Send the last VFA low vision or specialty contact lens consultation has been requested because the patient is having difficulty with the following tasks Distance Vision (seeing loved one’s faces, TV, stop lights) Near Tasks (Reading printed menu, newspaper, Cell Phone or medicine bottle) Intermediate Tasks (Navigator, crafts, computer) Mobility/Driving (safe walking, h/o tripping or falling) Photophobia (indoor and outdoor glare) Referring DoctorofEmail (Provide Feedback) CellFNames of the other eye care specialists the patient is currently seeing:*Please fax over the most recent records, including last visual field or topography/OCT. Δ
