Vision Therapy Referral Form (PDF) - Vision and Performance 2026

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

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