Patient Referral Form - Center for the Visually Impaired

Center For The Visually Impaired Patient Referral Form

Patient First Name(Required)

Patient Last Name(Required)

Date of Birth

Patient’s Preferred Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Diagnosis

Visual Acuities

Please Upload Patient Eye Report with Fundus and Slit Lamp Exam (within last 12 months) and Visual Field Testing and Report

Drop files here or

Max. file size: 32 MB, Max. files: 3.

Distance cc OD

Distance – cc OS

Referred by

Physician’s Name(Required)

Physician Practice/Location

NPI

Phone

Address

Street Address City State Zip

Referral Date

Date of Office Visit

This field is for validation purposes and should be left unchanged.

O U R M I S S I O N

The mission of the Center for the Visually Impaired is to empower people impacted by vision loss to live with independence and dignity.

This single goal guides the programs and services of the Center for the Visually Impaired (CVI), and we work in a variety of ways to achieve it.

From our roots working with children in the 1960s, CVI has emerged as a leader in vision rehabilitation and training services for people of all ages and degrees of vision loss. Annually CVI helps more than 1,000 children, adults and seniors acquire skills to succeed at school and work, be active members of their communities, and live safely and independently.

CVI also serves as a resource for thousands of people each year from 28 counties throughout metro Atlanta and beyond who are seeking answers and help for themselves or a loved one. Nearly 50% of our clients are from low-income households (earning less than 200% of the Federal Poverty Guidelines).

With the support of individuals, corporations, foundations, and organizations, CVI can ensure that anyone who needs services can access them. Philanthropy supports our ability to offer a sliding fee scale and other financial assistance to people with vision loss in our community.

Please explore our website to learn more about all our programs and services. Thank you for your interest and let us know how we can help you.

Center for the Visually Impaired
739 W. Peachtree St., NW
Atlanta, GA 30308
(404) 875-9011

Center For The Visually Impaired Patient Referral Form

Visual Acuities

Referred by

NAVIGATION

R E C E N T P O S T S

O U R M I S S I O N