Reasons For Referral Vision Therapy StrabismusAmblyopiaTracking / Oculomotor DysfunctionConvergence InsufficiencyAccommodative ProblemsDifficulty in SchoolNeurolens CandidateOther Specialty Contact Lenses Keratoconus/EctasiaPost Surgical CorneaSevere Dry EyeIrregular AstigmatismOther (Corneal Dystrophy,Degenerations, Scarring,etc.) Myopia Management Myopia ProgressionOrthokeratologyAtropineMultifocal Soft LensesCo-managementOther RESULTS OF EXAMINATION Refraction: OD OS VA OD VA OS Spec Rx OD Spec Rx OS YES I would like to co-manage this patientNO I would not like to co-manage, please treat as necessary and refer back for primary care services ADDITIONAL INFORMATION We will contact your patient within 48 hours of receiving this form. If the patient follows through with anevaluation, a copy of the results will be sent over to you. All patients will be referred back to you.We thank you kindly for the referral!
