Refer a patient
Thank you for choosing to refer your patient to Vision Loss Rehabilitation Canada for support with their vision loss. We encourage you to complete all fields on this form so that we can build the best possible rehabilitation plan for your patient; however, only those fields marked with an asterisk (*) are required.
Please email us at firstname.lastname@example.org if you have a problem submitting this form. If you prefer, you can download and complete an accessible version of the Health Care Professionals Referral Form (PDF) and send it by fax to 1-844-268-7294.