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Use this form to refer someone.

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    Patient Name


    Zip Code

    Visual Diagnosis

    Best Corrected Visual Acuity OD (Right)

    Best Corrected Visual Acuity OS (Left)


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    Additional Information (Optional)

    Referring Doctor

    Current Glasses Rx OD (Right)

    Current Glasses Rx OS (Left)

    Near Add OD (Right) & OS (Left)

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