Doctor Referral for Clinic Date MM slash DD slash YYYY Patient's Name(Required) First Last Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Dr. Ross Cusic will provide low vision care for every patient your refer. Every patient will return to you for continued medical care. Please Check Diagnosis Macular Degeneration Glaucoma Diabetic Retinopathy Cataract Pathological Myopia Optic Atrophy Stargardt Disease Juvenile Macular Disorders Macular Hole Nystagmus Fuch's Corneal Dystrophy Hemianopsia - Vision Loss After a Stroke or Brain Injury Other OtherReferring PhysicianPhysician's Phone Δ
