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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 A new iteration of this website has been launched and this referral form is no longer valid.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​​ should you have a problem submitting this form.​

Patient information


Patient's vision information

Distance VA (best corrected).
Near VA (best corrected).
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.