Vision Therapy Assessment Referral Form

Name: Dr Hopkins & Associates Optometry
Address: 358 Mary St., Niagara-on-the-Lake, ON, L0S 1J0, CA
Telephone: (905) 468-8002
Price range: $000 - $300

Section 1: Referring Healthcare Provider
Today's Date*
DD slash MM slash YYYY
Name*
First Last
Phone*
Fax
Email*
Section 2: Patient Information
Patient Name*
First Last
Date of Birth*
DD slash MM slash YYYY
OHIP Number*
Please enter a number from 10 to 10.
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Reason for Referral*
- Perceptual Evaluation
- Eye Tracking/Oculomotor
- Strabismus
- Accommodative Dysfunction
- Amblyopia
- Traumatic Brain Injury
- Binocular Dysfunction
- Concussion
Refraction & BCVA:
OD
OD 20/
Refraction & BCVA:
OS
OS 20/
Comments/ Relevant Examination Results:

Vision Therapy Assessment Referral Form

Section 1: Referring Healthcare Provider

Section 2: Patient Information

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Dr Hopkins & Associates Optometry

Dr Hopkins & Associates