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?
  1. Complete this HIPAA-compliant referral form.
  2. 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 *
Referring Doctor
Referring Doctor's Fax Number or Direct Secure Messaging Address *
Referring Doctor's Phone Number *
Patient Last Name *
Patient First Name *
Patient Date of Birth *
MM
/
DD
/
YYYY
Patient Phone Number *
Would you like us to contact the patient to schedule the appointment, or will you call our office to schedule? *
Patient's Best Corrected Acuity OD *
Patient's Best Correct Acuity OS *
A copy of your responses will be emailed to the address you provided.
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