Berkeley Lions Club Sight Saver Foundation

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Instruction:
Fill out a patient referral form from the Berkeley Lions Club Sight Saver Foundation (see attached blank form). Once the client fills out this form, it should be returned to the office of Dr. Mark Fujikawa at 2414 Shattuck Avenue, Berkeley 94704. (Note that extra forms can also be picked up at that location.) When the Lions Club receives the completed form, they will use it to request authorization from the Morgan Eye Center for a free exam & glasses, and the Morgan Eye Center will contact the client.

( Patient referral form)



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