Pacific EyeClinic Referral Form
Client's Name
*
First Name
Last Name
Client's D.O.B.
-
Month
-
Day
Year
Date
Client's Pronouns
Client's Mailing Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Client's phone number
Format: (000) 000-0000.
Does the client already have a valid prescription (Rx)? If YES, please remind client to bring their prescription to their appointment with Pacific EyeClinic.
*
YES (client understands that they will either have to go to Pacific Eye Clinic in Hillsboro, or Eye Promise Optical in NW Portland.
NO
Who is the sponsoring Lions Club/Agency?
*
Name of the person filling out this form
*
First Name
Last Name
Submitter's Email
*
example@example.com
There is a $20 dispensing fee, who will be paying it?
*
Your Client
Your Lions Club
Clinic receiving the referral
*
Please Select
Pacific EyeClinic - Beaverton
Pacific EyeClinic - Cornelius
Pacific EyeClinic - Forest Grove
*Pacific EyeClinic - Hillsboro
*Eye Promise Optical - Portland - Eyeglasses Only
*Hillsboro Clinic and Eye Promise Optical are the only two clinics who take outside prescriptions.
Notes/Comments
If you want a copy of this form sent to you, please supply us an email.
example@example.com
OLSHF "Sender" Name for Email Notifications
Clinic Location Test
Please Select
Submit
Should be Empty: