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 info@vlrehab.ca​ 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.

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 - 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:
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.