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Health Care Professionals Referral Form

​​Thank you for choosing to refer your patient to Vision Loss Rehabilitation [vlr:province] for assistance with their vision loss. Once we receive your submission, we will reach out to your patient to develop their rehabilitation plan. If you prefer, you can download and complete an accessible version of the Health Care P​​rofe​ssionals Referral Form (PDF)​​​ and send it by fax to 416-480-7700.​

 

We encourage you to complete all fields on this form in order​ for us to formulate the best possible plan for your patient. However, if you are unable to complete all fields, we can follow up with you to get further information.

Only those fields marked with an asterisk (*) are required. 

Please email us at info@vlrehab.ca​ should you have a problem submitting this form.

Informations sur le patient

Renseignements relatifs à la vision du patient

Vision de loin - acuité visuelle (avec meilleure correction)

Vision de près - acuité visuelle (avec meilleure correction)

Cause principale de la perte de vision

Cause secondaire de la perte de vision

Renseignements concernant le spécialiste qui recommande l’aiguillage

Je suis un:

*Prière de remplir tous les champs obligatoires avant de cliquer sur Soumettre.