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Contact Us
Our Eye Doctors
Eye Care Services
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- Orthokeratology
- MiSight 1 Day Contact Lenses
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- Contact Lenses
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Refer To Us

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Eye Care Services
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- Orthokeratology
- MiSight 1 Day Contact Lenses
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- Eyeglasses
- Contact Lenses
Blog
Refer To Us

Contact Us
Our Eye Doctors
Eye Care Services
Vision Therapy
Myopia Control (Ortho-K & MiSight)
- Orthokeratology
- MiSight 1 Day Contact Lenses
Dry Eye
Products
- Eyeglasses
- Contact Lenses
Blog
Refer To Us

Call 626-999-3177

Home » Refer To Us

Refer To Us

Date:(Required)

MM slash DD slash YYYY

Patient Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Mother's Name:

Father's Name:

Patient's Phone Number:(Required)

Patient's Email:

Referred By (Doctor/Health Professional's Name):(Required)

Clinic/Practice Name:(Required)

Clinic/Practice Phone Number:(Required)

Clinic/Practice Email:

REASONS FOR REFERRAL

VISION THERAPY

Vision Therapy

Learning-Related Vision Problems ( i.e. skipping words when reading, eye fatigue, headaches, poor reading comprehension, etc.)

Visual Processing Dysfunction ( i.e. letter reversals, reduced visual memory, poor handwriting, etc.)

Vision Therapy/Neuro-Optometric Rehabilitation

Eye Turn Inward or Outward ( Cross-eye, wandering eye, Strabismus )

Lazy-eye ( Amblyopia ) or Double Vision

Brain Injury Evaluation

Challenges in school/reading/work

Other

COMPREHENSIVE EYE EXAM

Comprehensive Eye Exam

Infant/Pediatric/ Children Eye Exam

Special Populations Eye Exam (i.e. Autism, Developmental delay, etc.)

Brain Injury Eye Exam (i.e. Concussion, Stroke, etc.)

Other

MYOPIA MANAGEMENT

Myopia Management

Orthokeratology

MiSight

Other

DRY EYE MANAGEMENT

Dry Eye Management

Dry Eye Evaluation

Dry Eye Therapy

Comments:

Thank you for kind referral. We will contact your patient upon receiving this form. You will be provided a report of the findings once the patient follows through with the evaluation. We always remind patients to continue their follow up care with you as well. Thank you for your trust in us.

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Vizen Optometric Center

Phone: 626-999-3177
Text: 626-999-3177
Fax: 626-345-1888
Toll Free: *Please note our previous phone number 888-988-4936 is still working but we will be transitioning our phone number to 626-999-3177.
Email: hello@vizen.care
(Do not send personal health information by email.)

360 E Las Tunas Dr Suite 203
San Gabriel, CA 91776

*Office hours may vary during this unprecedented time. Please call or text us to confirm. Thank you for understanding.

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Vizen Optometric Center - Located at 360 East Las Tunas Drive Suite 203, San Gabriel, CA 91776 Phone: 626-999-3177

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