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Home » Contact Us » Referral Request

Referral Request

Date

MM slash DD slash YYYY

Patient Name

First Last

Address

Street Address City State ZIP Code

Telephone

I am referring for the following reason(s):

Double Vision

Learning Related Visual Problems

Eye Strain

Post trauma/Stroke Evaluation

Dizziness and Balance Issues

Accommodative Dysfunction

Reading Problems

Developmental Delays

Driving

Exophoria/Esophoria/Hyperphoria

Fluctuating Acuity

Convergence Insufficiency

Strabismus/Amblyopia

Other

Other

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Thompson Optometry

Unit 3, 470 Chrysler Dr
Brampton, ON L6S 0C1

Phone: (905) 793-2020
Email: office@drrickthompson.ca
(Do not send personal health information by email.)
Fax: (905) 793-8528

Monday: 8:30 AM - 5:30 PM
Tuesday: 8:30 AM - 5:30 PM
Wednesday: 8:30 AM - 5:30 PM
Thursday: 8:30 AM - 5:30 PM
Friday: 8:30 AM - 5:30 PM
Saturday: 8:30 AM - 3:00 PM
Sunday: Closed

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Request An Appointment

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Thompson Optometry
Unit 3, 470 Chrysler Dr
Brampton, ON L6S 0C1
Phone: (905) 793-2020
https://www.drrickthompson.ca

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