Vision Therapy Assessment Referral Section 1: Referring Healthcare ProviderToday's Date* DD slash MM slash YYYY Name* First Last Phone*FaxEmail* Section 2: Patient InformationPatient 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: ODOD 20/ Refraction & BCVA: OSOS 20/ Comments/ Relevant Examination Results:
