Referrals

Contacting For:
- Optometrist or Ophthalmologist
- Allied Professional
Optometrist or Ophthalmologist
Patient Name*
First Last
DOB
MM slash DD slash YYYY
MSP #
Phone
Alternate Phone
Address
Street Address Address Line 2 City Province Postal Code
WCB or ICBC Claim #/Claim Manager
Reason For Referral
- Vision Related Learning Difficulty
- Binocular Coordination/Accommodative Dysfunction
- Strabismus or Amblyopia
- Acquired Brain Injury
- Sports Vision Training/Baseline Concussion Evaluation
Pertinent History
Medications
Refraction OD
Acuity OD (20/)
Refraction OS
Acuity OS (20/)
Binocular Vision Test Results
Ocular Health
Comments
Referring Optometrist or Ophthalmologist
Referring Clinic
Referring Clinic Phone#
Referring Clinic Fax#
Allied Professional
Client Name*
First Last
DOB
MM slash DD slash YYYY
MSP#
Phone
Alternate Phone
Address
Street Address Address Line 2 City Province Postal Code
Medications (if known)
History/Comments
Referring Professional
Referring Clinic, School or Organization
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Name
This field is for validation purposes and should be left unchanged.

201 - 880 Clement Avenue
Kelowna, BC
V1Y 0H8

[email protected]
1 (236) 420-4448
1 (778) 699-2067

Hours:
Sunday: CLOSED
Monday: 10am - 6pm
Tuesday: 10am - 6pm
Wednesday: 10am - 6pm
Thursday: 10am - 6pm
Friday: 9am - 5pm
Saturday: 9am - 4pm