Provider Referrals

Referring a patient is simple!

Either download and fax us the form below, or fill out and submit the form on the right!

We will contact the patient for you so you do not need to set the appointment up.

Please fax us over any relevant clinic notes from your evaluation, especially if you performed any imaging or visual fields testing.

Here are the faxable referral forms. Feel free to print them out and fax them to us if you prefer this method.

Our fax number is: 346-352-9156

Prior to a referral:

Please hold off/refrain from dispensing a glasses or contact lens prescription, as the prescription may need to be adjusted following our functional vision evaluation.

If we write a new prescription we will advise that the patient fills that at your office!

Referring Provider's Name

Referring Provider's Clinic

Referring Provider's Fax Number

Patient's Full Name

Patient's Date of Birth

Patient's Contact Email

Patient's Contact Phone Number

Please write the reason for your referral!

Contact Details

Texas Vision Therapy

19002 Park Row Suite 203

Houston, TX 77084

Phone: 832-684-9833

Fax: 346-352-9156

info@texasvisiontherapy.com

Office Hours

Monday through Thursday:

9:00 AM - 6:00 PM

Friday to Sunday:

Closed