Referral For Scleral & Other Specialty Lenses 2640 Golden Gate Pkwy, Suite 113 Naples, FL 34105 Phone: 239-908-4098Date(Required) MM slash DD slash YYYY Referred By(Required) Patient's Name(Required) First Last Age(Required)Contact Information: Hospital/Agency Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Best time to call Hours : Minutes AM PM AM/PM Date of Last Eye Examination: MM slash DD slash YYYY NOTE: The Following questions will reduce patient examination time and enable the patient to have their Scleral Lens evaluation at their initial visit. Without these answers or other supporting documentation, a comprehensive examination will be required prior to the evaluation to determine other contributing factors for decreased visual acuityResults of ExaminationPrevious CL Wearer? No Soft Lenses RGP Retinal Disease Affecting VA? Yes Probable/unsure No Cataract Affecting VA? Yes Probable/unsure No Corneal Disease Affecting VA? Yes Probable/unsure No Suggested Evaluation For:(Required) Scleral Hybrid RGP Custom Soft Bi-Toric Bifocal
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