Community Referral Form

Patient Information

Health Card number
Address
City
Postal Code
Telephone number (day time or cell)
Date of birth (D/M/Y)

1. How does the persons vision loss impact their quality of life?
Have they had a visit with their eye doctor in the last year?
Diagnosis
Eye Doctor’s Name:
2. Is the person currently in a hospital or rehabilitation facility?
Is this referral part of the discharge plan?
3. Is there additional assessment information to accompany this referral?
4. Person preferred language
Enter other…
If consent was provided by someone other than the person being referred. 
Alternate contact name
Relationship
Day time contact number
Completed by Referring
Organization/Relationship
Phone number
Name
Referral Date (D/M/Y)