Patient/Student Referral Form

Please complete this form if your student or patient may benefit from the services of Beyond Blindness. Important Warning: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any disclosure, copying or distribution of this information is Strictly Prohibited. If you have received this message by error, please notify the sender immediately to arrange for return or destruction. Unauthorized re- disclosure for failure to maintain confidentiality could subject you to penalties described in federal and state law.