Thank you for choosing to refer your patient to Vision Loss
Rehabilitation Manitoba 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 Professionals Referral Form (PDF) and send it
by fax to 204-775-5090.
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
Only those fields marked with an asterisk (*) are required.
Please email us at email@example.com should you have a problem
submitting this form.