Low Vision Assessment Referral Form

Phone: <a class="ecp-phone-call-phone" href="tel:905-939-8282" style="text-decoration:none"> 905-939-8282
Fax: 1-866-836-3167
Email: schomberg.eyecare@gmail.com (Do not send personal health information by email.)

Name: Schomberg Eye Care
Address: A10-50 Doctor Kay Drive, Schomberg, ON, L0G 1T0, CA
Telephone: 905-939-8282

Please complete the following online form. Thank you for your referral!

If you prefer, we have a Printable Form. Please send the completed form to Schomberg Eye Care via email: schomberg.eyecare@gmail.com or fax: 1-866-836-3167

Note: Fields marked with a red asterisk are required.
Patient name:*
First Last
Parent/Guardian (if applicable):
First Last
Patient's DOB:*
MM slash DD slash YYYY
Patient phone number:*
Patient email:
Patient address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient's chief complaint:*
Existing eye condition(s) and ocular history:
Date of most recent eye examination:*
Next scheduled follow up:
Additional Information:
Referring doctor's name:*
First Last
Referring doctor's address and contact information:*
Doctor's Signature
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.