Provider Referral Form Thank you for referring your patient. Our doctor team looks forward to collaborating with you! If you have a specific question or would like to consult with one of our doctors, please contact us directly at (425)787-5200 or email at info@alderwoodvisiontherapy.com Warm Regards, Nancy Torgerson, OD, FCOVDSylvianne Youngblood, ODCiara McCaffrey, ODBhavjit Mangat, ODAustin Jensen, OD, ODSamantha Del Campo, ODGuillermo Del Campo, OD, Patient Name* Date of Birth* Address* Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Best Contact Phone* Parent / Guardian Name (if applicable) Reason for Referral*AmblyopiaStrabismusConcussion / TBI/ Post stroke evaluationVisual processing concernsConvergence or other binocular vision concernsSaccade or other eye movement concernAccommodative DysfunctionEye strain / HeadachesDizzinessDiplopia (double vision)Infant / Preschool evaluationSpecial needs evaluationNystagmusother Additional Information Doctor or Professional Name* Practice Name Doctor or Professional Phone* Doctor or Professional Fax Area Code - Phone Number Doctor or Professional Email* Preferred method to follow-up*Fax chart notesEmailPhone call If you are sending this from an optometry or ophthalmology office, please attach or fax (425-787-5252) a copy of the most recent examination and glasses prescription and answer the following (if applicable):Glasses prescription finalizedI would like AVTC collaboration to finalize the prescriptionI am willing to comanage contact lens prescriptionsOptical carries tintsOptical carries Shaw Lenses Date of last exam*SubmitReset
