Refer a patient or client

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 would rather complete a PDF: Download and complete an accessible version of the Health Care Professionals Referral Form (PDF) and send it by fax to 1-844-268-7294.

Body

Health Care Professional Referral Form

Section one: Patient Information

VLRC office closest to the patient

Person's Health Card Number

First Name

Last Name

Person's Date Of Birth

Gender

Person's Telephone Number (day time or cell)

Street

City

Province

Postal Code

Country

Person's preferred language

If Other language, please specify

Alternate contact name

Alternate contact phone number

Section Two: Supplemental patient information

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?

Reason for referral (describe functional problems related to vision, e.g., the person struggles to read print):

If Other

Section Four: Eye examination and additional information

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

Eye Doctor's Name

Diagnosis

Is the person currently in a hospital or rehabilitation facility?

If Yes, is this referral part of the discharge plan?

Is there additional assessment information to accompany this referral?

If Other, please specify

Section Five: Consent

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

Date of Consent

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

Date of Substitute Consent

First name

Last name

Relationship

Day time contact number

Section Six: Referrer information

Referral completed by

If Other

First Name

Last Name

Address Line 1

Address Line 2

City/Town

Province/Territory

Country

Postal Code

Phone number

Fax

Contact Information