Patient Referral Form

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 info@vlrehab.ca if you have a problem submitting this form. If you prefer, you can download and complete an accessible version of the Eye Care Professionals Referral Form (PDF) and send it by fax to 1-844-268-7294.

Body

Eye Care Professional Referral Form

Section One: Patient Information

Referral Date

Patient's Health Card Number

Date of Birth

Patient's first name

Patient's last name

Gender

Address 1

Address 2

City

Province or Territory

Postal Code

Patient's phone number

Alternative phone number

Country

Person's preferred language

If Other language, please specify

Alternate contact name

Phone number of alternate contact name

Section Two: Supplemental patient information

VLRC office closest to the patient

Do you (the person being referred) identify as an Indigenous person, such as First Nation, Inuk (Inuit), or Métis?

If yes, please select from the following.
If number is not known please type “Number not known” in the appropriate text box:

This is a multi select - Use Control + Select to choose multiple options

First Nations-Indian Act Registration number

First Nations-NIHB ID (B Number)

Métis Sponsorship-Band#+Family#

Métis-Indian Act Registration number

Inuk/Inuit-North West Territories Health Plan Number

Inuit-Government of Nunavut Health Plan Number

Inuk/Inuit-NIHB (N Number)

Are you (or the person being referred) a current, former or retired member of the Canadian Armed Forces or the Royal Canadian Mounted Police (RCMP)?

If yes, can you provide a K-number?

If yes, please provide K-number?

Section Three: Reason(s) for referring the patient

Impact of vision loss on the patient's quality of life? (e.g., safety, job/academic, daily living, other):

Due to the patient's vision loss, have they experienced a fall within the last 3 months?

Due to the patient's vision loss, have they experienced burns?

Due to the patient's vision loss, are they at risk of job loss?

Due to the patient's vision loss, are they at risk of academic failure?

Due to the patient's vision loss, have they accidentally taken the wrong medication?

Section Four: Eye Examination and Additional Information

Has there been an eye doctor examination in the past 12 months?

Examination Date

Eye Doctor's Name

Diagnosis

Section Five: Patient Vision Information (To be completed by eye care professional)

Date of Exam

Prescriber Name

Distance VA (best corrected)

OD (right eye)

Other

OS (left eye)

Other

OU (both eyes)

Other

Near VA (best corrected)

OD (right eye)

Other

OS (left eye)

Other

OU (both eyes)

Other

Rx OD (right eye)

Add

Rx OS (left eye)

Add

Current correction is the same as the Rx for both OD and OS

Current Correction - OD (right eye)

Add

Current Correction - OS (left eye)

Add

Visual Field

Visual field

Describe field loss - OD (right eye) Visual field in degrees

Field loss description

Describe field loss - OS (left eye) Visual field in degrees

Field loss description

Primary Cause of Vision Loss

OD (right eye)

Other

OS (left eye)

Other

Secondary Cause of Vision Loss

OD (right eye)

Other

OS (left eye)

Other

Primary functional reason for referral (e.g., the person struggles to read print):

Other medical conditions or limitations

If Other

Section Six: Consent

Is the person aware of this referral and has provided their consent?

Date consent given

If consent is provided by a substitute decision-maker, please complete the following:

Consenting person's first name

Consenting person's last name

Relationship to the patient

Contact number

Date of substitute consent

Section Seven: Referrer Information

Referral completed by

If Other

First name

Last name

Clinic or Office Street Address Line 1

Clinic or Office Address Line 2

City/Town

Province/Territory

Postal Code

License to Practice #

Phone number

Fax

Contact Information