Professional Referrals

Details of Referring Professional:

First Name

Last Name

Contact Number: *

(###)

###

####

My client/patient presents with the following problems: *

Visual stress or visual processing issues

Difficulties with reading fluency

Slow reading speed

Frequent loss of place when reading

Skipping words or lines while reading

Headaches or eye strain when reading

Words or letters moving / blurring on the page

Reversals of letters or numbers

Light sensitivity / glare sensitivity

Complaints of visual discomfort (e.g. sore eyes, watering, rubbing)

Other

Patient/Cllient Details:

First Name

Last Name

Patient/Client Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient/Client Phone Number:

(###)

###

####