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How to use or fill out Vision Therapy Referral Form (PDF) - Vision and Performance
- Click ‘Get Form’ to open it in the editor.
- Begin by entering the clinic name and phone number at the top of the form. This information is essential for proper identification.
- Select the type of developmental vision care requested by checking one of the options provided: consult only, evaluation, or other.
- Fill in the patient's name, date of birth, diagnosis, and optional code. Ensure accuracy as this information is crucial for patient records.
- Complete the parent/guardian's name and address fields, including city, state, and zip code. Provide a daytime phone number for contact purposes.
- Indicate today’s date to document when the referral is made.
- Enter the referring professional's name to ensure proper communication between parties.
- Check all applicable conditions that apply to the patient. This helps in understanding their specific needs.
- Provide any pertinent diagnostic findings and comments in the designated section for additional context.
- Ensure signatures from both tech/staff and doctor are included before finalizing the form.
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