Low Vision Referral Form Date MM slash DD slash YYYY Patient's Name(Required) First Last Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Dr. Terry Smith will provide low vision care for every patient your refer. Every patient will return to you for continued medical care. Please Check Diagnosis Macular Degeneration Stargardt Disease Glaucoma Juvenile Macular Disorders Diabetic Retinopathy Macular Hole Cataract Nystagmus Pathological Myopia Fuch's Corneal Dystrophy Optic Atrophy Hemianopsia - Vision Loss After a Stroke or Brain Injury Albinism Other OtherReferring PhysicianPhone Δ
