LevensonEyeAssociates.com | 904-366-3781
Jeffrey H. Levenson, M.D.
Frank W. McDonald, M.D.
Hannah Miller, M.D.
Walter Smithwick, IV, M.D.
Samuel Homra, M.D.
Curtis Schmidt, O.D.
Ronald Singal, M.D.
Elizabeth McLeod, M.D.
William Knauer, M.D.
Patient Referral
Type of Appointment
Urgent
Routine
Date
Referring Physician Information
Referring Physician
MD
OD
NPI#
Practice Name
Address
City
State
Zip
Phone
Fax
Email
Patient Information
Patient Name
(Legal Name)
Date of Birth
Sex
Home Phone
Cell Phone
Email
Referring to
Jeffrey H. Levenson, M.D.
Walter Smithwick, IV, M.D.
Ronald Singal, M.D.
Frank W. McDonald, M.D.
Samuel Homra, M.D.
Elizabeth McLeod, M.D.
Hannah Miller, M.D.
Curtis Schmidt, O.D.
William Knauer, M.D.
Appointment for
Comprehensive Ophthalmology
Diabetic Retinopathy
Flashers & Floaters
Oculoplastics (Blepharoplasty)
Cataracts
Corneal Dystrophies
Keratoconus
Corneal Transplantation
Glaucoma
Age-Related Macular Degeneration (AMD)
Specialty & Therapeutic Contact Lens Care
Is this your first referral to Levenson Eye Associates?
Yes
No
Additional Information and Description of Referral
Riverside Park Place
51 Oak Street
Suite 200
Jacksonville, FL 32204
Mandarin
3020 Hartley Road
Suite 190
Jacksonville, FL 32257
Orange Park
905 Park Avenue
Suite 104
Orange Park, FL 32073
Ponte Vedra Beach
120 A1A North
Suite 102
Ponte Vedra Beach, FL 32082
Knauer Building
2535 Riverside Avenue
Jacksonville, FL 32204