Thank you for requesting your digital copy of Avella's Ophthalmology Rx Form.
This form includes the following medications:
- DISODIUM EDETATE
- INDOCYANINE GREEN
To ensure you receive the most updated referral forms in the future, we request that you submit your contact information. By doing so, we will provide you with the latest version by email.
If you wish to continue downloading, but do not want to provide your contact information, simply click here to access the form.