Skip to Main Content
  • Select Province:
  • Français
  • Print
  • Change Contrast
  • Text Resize

Referrals - Banner
Health Care Professionals Referral Form

Thank you for choosing to refer your patient to Vision Loss Rehabilitation Canada for assistance with their vision loss. A new iteration of this website has been launched and this referral form is no longer valid. If you wish to submit a referral please use the form found at the following link: New Health Care Professions Referral Form

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

Patient information

 
   
 
 
 
 
 
 
 
 
 
 

Patient's vision information

Distance VA (best corrected).
Near VA (best corrected).
Rx
Rx
Current correction is the same as the Rx for both OD and OS
Describe field loss - OD (right eye)
Describe field loss - OS (left eye)
Primary cause of vision loss
Secondary cause of vision loss
 

Referrer information


*I am an:
 
 
 
 
 
 
 
*Please fill in all mandatory fields before hitting submit.