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.

Patient information

Date of most recent eye examination (YYYY-MM-DD)

Patient's date of birth (YYYY-MM-DD)

Patient's first name

Patient's last name

Patient's street address

Patient's city

Patient's province or territory

Patient's postal code

VLRC office closest to patient

Patient's phone number

Patient's provincial health card number

Alternate contact name

Phone number of alternate contact name

Patient has consented to the release of this information to VLRC

Patient's vision information

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

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., patient struggles to read print)

Other medical conditions or limitations (e.g. arthritis, diabetes)

Referrer information

I am an:

Ophthalmologist

Optometrist

Neuro-ophtalmologist

Other health care professional

First name

Last name

Clinic or office street address

City

Province or Territory

Postal code

Doctor's license to practice number

Phone

Fax

*Please fill in all mandatory fields before hitting submit.