Please use the form below to refer a patient to The Lighthouse. Learn more about our Services and Programs by visiting our Clinical Services Home Page.
Please use the Referral to Lighthouse International for Vision Rehabilitation form to connect your patients with our services. You may fax the form to (212) 821-9710. Upon receipt we will contact the patient to arrange for the services that meet the individual's needs. PLEASE NOTE: This form is only to be used to refer patients in the 5 boroughs of NYC (Brooklyn, the Bronx, Queens, Staten Island, and Manhattan).
Only the patient's contact information and physician's name are necessary to make the referral. You may also fill out the section on functional difficulties, as noted on the form, but this is optional. We greatly appreciate the opportunity to work with you and your patients and will provide feedback following their appointments.
We look forward to helping your patients who have vision loss, so that they can function as independently -- and safely -- as possible in their daily lives.
Download the referral form, now!
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