Referral Form VT Referral Form Patient Information First Name Last Name Age Date of Birth Parent/Guardian Name (if applicable) Address Street Address Address Line 2 City Province Postal Code PhoneEmail Date MM slash DD slash YYYY Referring Professional's Contact Details First Name Last Name Name of Practice Referral's Address Street Address Address Line 2 City Province Postal Code Referral's PhoneReferral's Email Reason(s) for Referral Binocular Vision Disorder Accommodative Difficulties Strabismus/Amblyopia Visual Perceptual Problems Problems with Attention History of Concussion Eyestrain/Headaches Diplopia Convergence Insufficiency/Excess Poor Handwriting Developmental Delays Neuro-Optometric Vision Evaluation Tracking/Oculomotor Dysfunction Difficulty with Reading Trouble Copying from Board Difficulty seeing 3D/Stereo Vision Other: Refraction Wet Dry OD VA Current Spec Rx OS VA Current Spec Rx no ocular health abnormalities noted (DFE performed) Other: Additional information:I hereby grant permission for Dr. K. Dolman and any other professional involved in my care to exchange information concerning my case, history, results of the examination, diagnoses, treatment, etc. I also hereby give my permission to have this information faxed to Dr. K. Dolman so that her office can contact me (or my appointed representative) to schedule an evaluation. Patient/Parent Name I hereby agreeDate Professional's Name I have obtained consent from the patientDate Print Referral Form