Referral Form Patient Information Medical Insurance Information (Vision if patient has medically necessary contact lens benefit): Reason For Referral Myopia management/OrthokeratologyKeratoconus/Specialty Contact Lens EvaluationEmergency Red Eye/Foreign body removalHigh Risk MedicationDry Eye EvaluationGlaucoma Evaluation Request for Release of Medical Records I authorize and request you to release all of my complete medical records to Vision Eye Max. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
