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Myopia Management Referral Form
Doctor Name
*
Practice Name
*
Patient Name
*
Patient DOB
*
Month
Month
Day
Year
Patient Phone
*
Would you like to co-manage?
*
YES, I would like to co-manage this patient.
NO, I would not like to co-manage. Please treat as necessary and refer back for primary care services.
Comments
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Please fax a copy of the last Routine Vision Exam to 253-954-1160.
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