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ViewFinder Referral Form
Please complete the form below and fax a copy of the patient’s most recent eye exam to either our Mesa (480) 854-1864 or Sun City office (623) 583-1556
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Patient Name
Your answer
Patient Address
Your answer
Patient City/Zip
Your answer
Patient Phone
Your answer
Patient Date of Birth
MM
/
DD
/
YYYY
Patient Primary Insurance Policy
Your answer
Diagnosis/Cause of Vision Loss
Your answer
Best Corrected Visual Acuity: OD
Your answer
Best Corrected Visual Acuity: OS
Your answer
A low vision evaluation is being requested because patient is having difficulty with the following:
Near Tasks (reading print, mail, managing finances, etc.)
Distance Tasks (driving, seeing faces, watching television, etc.)
Photophobia (difficulty with glare or visual discomfort)
Mobility (constricted visual field)
Vocational (maintaining or finding work)
Other:
Referring Doctor’s Name
Your answer
Clinic Name
Your answer
Address
Your answer
Phone
Your answer
Fax
Your answer
Clinic direct e-mail for correspondence
Your answer
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