Low Vision Referral - Scarborough Eye Care

Low Vision Referral

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Date

Referring Practitioner

Phone

Fax

Patient Name

DOB (m/d/y)

Phone

Address

Alternate Contact Info

Distance VA: OD

OS

Date of Exam (m/d/y)

Visual Fields attached

<20°OU

Normal

Diagnoses

Other Medical Conditions

Comments

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Dr. Angela Yoon

Optometrist

3030 Lawrence Ave. E Suite 106
Scarborough, ON M1P 2T7

Phone: (416) 438-3525
Fax: (416) 438-1305

USEFUL INFORMATION

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