Self and Community Referral - DRAFT

Self & Community Referral

cid

EVRR ID

Section One: Information of the person being referred

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

Section Two: Supplemental personal 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

Inuit-Government of Nunavut Health Plan Number

Inuk/Inuit-NIHB (N Number)

Inuk/Inuit-North West Territories Health Plan Number

First Nations-Indian Act Registration number

First Nations-NIHB ID (B Number)

Métis-Indian Act Registration number

Métis Sponsorship-Band#+Family#

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 referral

How does the person’s vision loss impact their quality of life? (e.g., safety, job/academic, daily living, other):

Due to your vision loss, have you (the person being referred) fallen within the last 3 months?

Due to your vision loss, have you (the person being referred) burned yourself?

Due to your vision loss, are you (the person being referred) at risk of losing your job?

Due to your vision loss, are you (the person being referred) at risk of academic failure?

Due to your vision loss, have you (the person being referred) taken the wrong medication?

Other Reason for the Referral

Referral Notes

Section Four: Eye examination and other 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?

Section Five: Consent

If you are referring yourself, do you consent to releasing your information to VLRC?

If you are referring someone, are they aware of this referral and have they provided their consent to release their information to VLRC?

If a substitute decision-maker is providing consent on behalf of the person being referred please complete the following:

Alternate contact first name

Alternate contact last name

Relationship

Day time contact number

Section Six: Referring agency information

Referral completed by

Name of person making referral

Organization/Relationship

Phone number

Contact Information