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

MonthDayYear
Patient’s Name
Referred By
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information: Parent/Guardian/Hospital/Agency
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pertinent Symptoms/ History:
Reason(s) for Referral:

School ProblemVisual Discomfort/HeadachesPost Trauma/Stroke EvaluationStrabismusAmblyopiaAsthenopiaComputer StrainOther
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

MonthDayYear
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.
Should be Empty: