Advancedvisionoflouisville

Daniel Weinberg, O.D., F.C.O.V.D.
Zachery Weinberg, O.D.
4414 Shelbyville Road, Suite 204
Louisville, Kentucky 40207
FAX 502.894.9912

FUNCTIONAL/DEVELOPMENTAL VISION EVALUATION FAX REFERRAL FORM

Date

Patient’s Name

Referred By

Age

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Contact Information: Parent/Guardian/Hospital/Agency

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Pertinent Symptoms/ History:

Reason(s) for Referral:

School Problem Visual Discomfort/Headaches Post Trauma/Stroke Evaluation Strabismus Amblyopia Asthenopia Computer Strain

Results of Examination

Eyeglass Rx

OD

VA OD

OS

VA OS

Binocular Status:

Eye Health:

I hereby grant permission for Dr. Weinberg and any other practitioner involved in my care to exchange information concerning my case, history, results of examination, diagnoses, treatment, etc. I hereby give permission to have this information faxed to Dr. Weinberg so that his office can contact me (or an appointed representative) to schedule an evaluation.

Patient/Parent Signature

Clear

Date

A copy of all tests results and a report will be sent to the referring doctor.
Please call Dr. Weinberg’s office at (502) 894-4434 if a report has not been received in a timely fashion.
Patients will return to referring doctor’s office for all primary care and eyeglass prescriptions.