Patient Forms

Download Patient Forms

If you are considering Vision Therapy for you or a loved one please take a moment to print and fill out both questionaires as appropriate and fax, mail or bring with you to your first appointment.

Download, print, and sign the appropriate forms as they might relate to your first visit to Arlington Vision Therapy.

Primary Questionnaire

This first questionnaire (.pdf) covers standard patient information, insurance information (if any), and emergency contacts information.
Download ...

Medical/Visual Health Questionnaire

This questionnaire (.pdf) covers your basic general and visual health history, and helps us to be able to better assess any possible current conditions you might be having or would like to have addressed during your visit.
Download ...

Symptom Checklist

This questionnaire (.pdf) attempts to assess any difficulties your child might be having with vision and vision related activities.
Download ...

These forms are written in .pdf file format and requires a free plugin that may have come included with your browser. If you are having difficulties opening these files then you may not have the plugin or addon installed in your browser — Please go to Adobe’s website and download/install the Adobe Reader.

If for some reason that you do not care for the Adobe Reader, you can download and install the independent Free File Viewer.

AVT Optical

Eyeglass Repair - Laser Welding, Custom Fitting Eyeglasses, Professional service and integrity.

Holistic Counselor

MaryVan Pham - Energy Therapist
Healing From Within

(360) 888-7555

Contacts

5906 Cemetery Road
Arlington, WA 98223

Phone: (360) 474-9620
Fax: (360) 435-2462
Toll Free: (866) 622-7161

Business Hours

Mon 2:00 pm - 6:00 pm
Tue, Wed, Thu 8:00 am - 5:00 pm
Fri 8:00 am - Noon

We're located about one mile west from highway 9 and three miles east from the I5 Smokey Point exit.