How to Refer a Patient for Low Vision Care

We truly appreciate you taking the time to discuss Low Vision care with your patients and referring them for this quality-of-life-enhancing service.

We understand how busy your day can get, so we’ve made it easy for you to refer patients in whichever way works best for you:

(760) 532-0334

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Ways To Refer:

1. Complete our online referral form

Online Referral Form

2. Download and use our PDF referral form

Download PDF

2. Have your patient call our office directly

Call (760) 532-0334

Thanks for contacting us! We will get in touch with you shortly.

Patient Name *

First

Last

Date Of Birth *

Day

Month

Year

Date Of Exam *

Day

Month

Year

Parent/Guardian Name

First

Last

Address *

Street Address

City

State

Zip

Phone (Main) *

Phone (Alternate)

Preferred person and phone for us to call to set up an appointment.

Referring doctor or other individual (name, fax, phone, email)

Reason for referral

Low Vision

Additional Information

If you are sending this from an optometrist or ophthalmologist's office, please send in a copy of the most recent exam (within one year)

Request a Low Vision Appointment today

If you have any questions or concerns, speak with our staff at Low Vision Provider and schedule a consultation. Let us help enhance your central vision and help you find the best way to enjoy a higher quality of life.

(760) 532-0334

Book Appointment