Get the free Low Vision referral form - Emory Eye Center

EMORY EYE CENTER DEPARTMENT OF LOW VISION SERVICES REFERRAL FORM URGENT? YESNOPATIENT NAME: DOB: ADDRESS: PHONE NUMBER(S): REFERRED TO (PLEASE CIRCLE ONE): First Available Susan Prime OD, MPH, FAAOKenneth

How to fill out low vision referral form

How to fill out low vision referral form

1. To fill out the low vision referral form, follow these steps:
2. Start by entering the patient's personal information, such as name, age, gender, and contact details.
3. Record the patient's medical history, including any existing eye conditions, visual acuity, and notable symptoms.
4. Specify the reason for the referral, indicating the specific low vision concerns or issues the patient is facing.
5. Include any relevant test results or examinations that have been conducted so far.
6. Provide a detailed description of the patient's functional vision abilities, including the impact of the visual impairment on daily activities.
7. Mention any assistive devices or visual aids currently being used by the patient to manage their low vision.
8. If applicable, note any previous low vision assessment or rehabilitation that the patient has undergone.
9. Finally, sign the referral form, including your name, designation, and contact information.

Who needs low vision referral form?

1. The low vision referral form is typically required by healthcare professionals, optometrists, or ophthalmologists who suspect that a patient is experiencing significant visual impairment or low vision.
2. Patients who have difficulty performing daily activities due to vision loss or those requiring specialized low vision services can also benefit from the referral form.
3. Moreover, individuals seeking access to low vision aids, devices, or rehabilitation programs may need to fill out a low vision referral form to initiate the process.

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What is low vision referral form?

Low vision referral form is a document used to refer individuals with low vision to eye care professionals for further evaluation and treatment.

Who is required to file low vision referral form?

Individuals with low vision or their caregivers are typically required to file the low vision referral form.

How to fill out low vision referral form?

To fill out the low vision referral form, individuals need to provide personal information, details of their vision impairment, and the reason for seeking referral.

What is the purpose of low vision referral form?

The purpose of the low vision referral form is to facilitate access to appropriate eye care services for individuals with low vision.

What information must be reported on low vision referral form?

Information such as name, contact details, vision impairment diagnosis, and reason for referral must be reported on the low vision referral form.