Lakeshore referral form 2026

1. Click ‘Get Form’ to open the lakeshore referral form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's first name, last name, middle initial, phone number, date of birth, and street address along with city and zip code.
3. Next, move to the 'Referring Optometrist' section. Clearly print your name, phone number, fax number, address, city/town, state (Illinois), and zip code.
4. In the 'Reason for Consultation' field, provide a detailed explanation of why you are referring the patient. Use multiple lines if necessary to ensure clarity.
5. Sign and date the form in the designated area as the referring optometrist. Ensure that all information is accurate before submission.
6. Finally, have the patient read and sign the 'Patient Statement' section to confirm their understanding of the referral process.

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