Forms

If you are a physical or occupational therapist considering referring a patient to the PRI Vision Clinic, please fill out the PRI Vision Program Triage Forms below.  If you are a clinician from another discipline other than physical or occupational therapy (dentist, physician, optometrist, etc.), OR if you are self-referring, please fill out the PRI Vision Self Assessment Forms below.  Fax the completed forms to Kelly at the Hruska Clinic at 402-467-4580.  Once the PRI Vision Triage/Self Assessment Forms are received, Ron Hruska, PT and Dr. Heidi Wise, OD, FCOVD will review the information and determine if the patient is an appropriate candidate for the PRI Vision Clinic.  Kelly will then be in contact with the referring clinician/patient to give them further instructions on scheduling.  Please do not have your patient call to schedule an appointment unless they have already been contacted by Kelly.  Dr. Wise is typically in the PRI Vision Clinic on Tuesdays and Thursdays, therefore it may be a few days before you receive further information after faxing the PRI Vision Triage/Self Assessment Forms.  Thank you.

PRI Vision Referral Recommendations

PRI Vision Program Triage Forms

PRI Vision Self Assessment Forms

Pre-requisites Needed for Successful PRI Vision Intervention

COURSE REGISTRATION FORM - Postural-Visual Integration

COURSE REGISTRATION FORM - Vision and Body Mechanics: Beyond 20-20