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Scott Eye Care Specialty/Scleral Contacts Referral Form
Do you have a patient you'd like to refer to Scott Eye Care for specialty contact lenses?
Complete this HIPAA-compliant referral form.
Please fax the patient's records to 337-706-8172 or use our HIPAA-compliant Direct Secure Messaging address at rcazares@direct.revolutionehr.com.
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Email
*
Your email
Referring Doctor
Your answer
Referring Doctor's Fax Number or Direct Secure Messaging Address
*
Your answer
Referring Doctor's Phone Number
*
Your answer
Patient Last Name
*
Your answer
Patient First Name
*
Your answer
Patient Date of Birth
*
MM
/
DD
/
YYYY
Patient Phone Number
*
Your answer
Would you like us to contact the patient to schedule the appointment, or will you call our office to schedule?
*
I would like Scott Eye Care to contact the patient for scheduling.
I will call Scott Eye Care to schedule the patient myself. (Our phone: 337-704-2260)
Patient's Best Corrected Acuity OD
*
Your answer
Patient's Best Correct Acuity OS
*
Your answer
A copy of your responses will be emailed to the address you provided.
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