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Health Care Professionals Referral Form

​​Thank you for choosing to refer your patient to Vision Loss Rehabilitation Ontario 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.

Patient information

Date of most recent eye examination (YYYY-MM-DD)
Patient's date of birth (YYYY-MM-DD)
Patient's first name
Patient's last name
Patient's street address
Patient's city
Patient's province or territory
Patient's postal code
VLRC office closest to patient
Patient's phone number
Patient's provincial health card number
Alternate contact name
Phone number of alternate contact name
Patient has consented to the release of this information to VLRC

Patient's vision information

Distance VA (best corrected).

OD (right eye)
Other
OS (left eye)
Other
OU (both eyes)
Other

Near VA (best corrected).

OD (right eye)
Other
OS (left eye)
Other
OU (both eyes)
Other
Rx OD (right eye)
Add
Rx OS (left eye)
Add
Current Correction - OD (right eye)
Add
Current Correction - OS (left eye)
Add
Visual field
Describe field loss - OD (right eye) Visual field in degrees
Field loss description
Describe field loss - OS (left eye) Visual field in degrees
Field loss description

Primary cause of vision loss

OD (right eye)
Other
OS (left eye)
Other

Secondary cause of vision loss

OD (right eye)
Other
OS (left eye)
Other
Primary functional reason for referral (e.g., patient struggles to read print)
Other medical conditions or limitations (e.g. arthritis, diabetes)

Referrer information

I am an:
First name
Last name
Clinic or office street address
City
Province or Territory
Postal code
Doctor's license to practice number
Phone
Fax

*Please fill in all mandatory fields before hitting submit.