Diabetic Retinopathy Screening Program Referral Form Patient Information Health Card Number Health Card Number Legal Name Legal Name Address Address City City Postal Code Postal Code Telephone (day time or cell) Telephone (day time or cell) Date of Birth (YYYY-MM-DD) Date of Birth (YYYY-MM-DD) 1. Does this person have any existing vision loss? Yes No Diagnosis Diagnosis 2. Eye Doctor’s Name and Location 2. Eye Doctor’s Name and Location 3. Primary Care Provider Name 3. Primary Care Provider Name 4. Persons preferred language English French Other Enter other… Enter other… Completed by: Name Name Phone Number Phone Number Organization Organization Referral Date (YYYY-MM-DD) Referral Date (YYYY-MM-DD) Submit
