reception@okanaganvisiontherapy.ca

1 (236) 420-4448

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Contacting For:
- Optometrist or Ophthalmologist
- Allied Professional
Optometrist or Ophthalmologist
Patient Name*
First Last
DOB
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
- Concussion & Brain Injury
- Sports Vision Training
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
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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Call

1 (236) 420-4448 | 1 (778) 699-2067

Email

reception@okanaganvisiontherapy.ca

Location

201 – 880 Clement Avenue, Kelowna, BC,
V1Y 0H8

Visiting Hours