Physician Referral Form Patient information Date of most recent eye examination (YYYY-MM-DD) Date of most recent eye examination (YYYY-MM-DD) Patient's date of birth (YYYY-MM-DD) Patient's date of birth (YYYY-MM-DD) Patient's first name Patient's first name Patient's last name Patient's last name Patient's street address Patient's street address Patient's city Patient's city Patient's province or territory Patient's province or territory - Select -AlbertaBritish ColumbiaSaskatchewanManitobaOntarioQuebecNew BrunswickNova ScotiaNewfoundland and LabradorPrince Edward IslandNunavutNorthwest TerritoriesYukon Patient's postal code Patient's postal code VLRC office closest to patient VLRC office closest to patient - Select -AB - CalgaryAB - EdmontonAB - Grande PrairieAB - LethbridgeAB - Medicine HatAB - Red DeerBC - AbbotsfordBC - KamloopsBC - KelownaBC - Prince GeorgeBC - VancouverBC - VictoriaMB - BrandonMB - WinnipegNB - BathurstNB - FrederictonNB - MonctonNB - Saint JohnNL - Corner BrookNL - Grand Falls-WindsorNL - LabradorNL - St. John'sNS - HalifaxNS - SydneyNT - YellowknifeON - BarrieON - BellevilleON - BrantfordON - CornwallON - HamiltonON - KingstonON - LondonON - MississaugaON - NewmarketON - North BayON - OshawaON - OttawaON - Owen SoundON - PeterboroughON - Sault Ste. MarieON - St. CatharinesON - SudburyON - TimminsON - Thunder BayON - TorontoON - WaterlooON - WindsorPE - CharlottetownQC - MontrealSK - ReginaSK - Saskatoon Patient's phone number Patient's phone number Patient's provincial health card number Patient's provincial health card number Alternate contact name Alternate contact name Phone number of alternate contact name Phone number of alternate contact name Patient has consented to the release of this information to VLRC Patient has consented to the release of this information to VLRC - Select -YesNo Date consent given (YYYY-MM-DD) Date consent given (YYYY-MM-DD) If consent was provided by someone other than the person being referred, please list their name, relationship to the patient and contact number: Name Name Relationship to the patient Relationship to the patient Contact number Contact number Patient's vision information Distance VA (best corrected). OD (right eye) OD (right eye) - None -20/2020/2520/3020/4020/5020/6020/7020/8020/10020/15020/20020/400Counting FingersHand MotionLight PerceptionNo Light PerceptionOther Other Other OS (left eye) OS (left eye) - None -20/2020/2520/3020/4020/5020/6020/7020/8020/10020/15020/20020/400Counting FingersHand MotionLight PerceptionNo Light PerceptionOther Other Other OU (both eyes) OU (both eyes) - None -20/2020/2520/3020/4020/5020/6020/7020/8020/10020/15020/20020/400Counting FingersHand MotionLight PerceptionNo Light PerceptionOther Other Other Near VA (best corrected). OD (right eye) OD (right eye) - None -20/2020/2520/3020/4020/5020/6020/7020/8020/10020/15020/20020/400Counting FingersHand MotionLight PerceptionNo Light PerceptionOther Other Other OS (left eye) OS (left eye) - None -20/2020/2520/3020/4020/5020/6020/7020/8020/10020/15020/20020/400Counting FingersHand MotionLight PerceptionNo Light PerceptionOther Other Other OU (both eyes) OU (both eyes) - None -20/2020/2520/3020/4020/5020/6020/7020/8020/10020/15020/20020/400Counting FingersHand MotionLight PerceptionNo Light PerceptionOther Other Other Rx OD (right eye) Rx OD (right eye) Add Add Rx OS (left eye) Rx OS (left eye) Add Add Current correction is the same as the Rx for both OD and OS Current Correction - OD (right eye) Current Correction - OD (right eye) Add Add Current Correction - OS (left eye) Current Correction - OS (left eye) Add Add Visual field Visual field - None -NormalAbnormal Describe field loss - OD (right eye) Visual field in degrees Describe field loss - OD (right eye) Visual field in degrees - None ->150150-121120-8180-6040-2120-1110-65-1 Field loss description Field loss description - None -Hemianopsia - BitemporalHemianopsia - BinasalHemianopsia - Homonymous (Right)Hemianopsia - Homonymous (Left)Hemianopsia - Quadrantanopsia (Upper Left)Hemianopsia - Quadrantanopsia (Upper Right)Hemianopsia - Quadrantanopsia (Bottom Left)Hemianopsia - Quadrantanopsia (Bottom Right)Central ScotomaParacentral ScotomaPeripheral ScotomaHemianopic Scotoma Describe field loss - OS (left eye) Visual field in degrees Describe field loss - OS (left eye) Visual field in degrees - None ->150150-121120-8180-6040-2120-1110-65-1 Field loss description Field loss description - None -Hemianopsia - BitemporalHemianopsia - BinasalHemianopsia - Homonymous (Right)Hemianopsia - Homonymous (Left)Hemianopsia - Quadrantanopsia (Upper Left)Hemianopsia - Quadrantanopsia (Upper Right)Hemianopsia - Quadrantanopsia (Bottom Left)Hemianopsia - Quadrantanopsia (Bottom Right)Central ScotomaParacentral ScotomaPeripheral ScotomaHemianopic Scotoma Primary cause of vision loss OD (right eye) OD (right eye) - None -AchromatopsiaAlbinismAmblyopiaAniridiaAnisometropiaAphakiaBlepharospasmBranch Retinal Artery Occlusion (BRAO)Branch Retinal Vein Occlusion (BRVO)CataractCentral Retinal Artery Occlusion (CRAO)Central Retinal Vein Occlusion (CRVO)ChoroiditisColobomaColoboma - Full ThicknessColoboma - IrisColoboma - RetinalCorneal DiseaseCorneal Disease - Corneal DystrophyCorneal Disease - Corneal EdemaCorneal Disease - Corneal Transplant (PKP)Corneal Disease - Fuch's DystrophyCorneal Disease - Herpes KeratitisCorneal Disease - InfectionCorneal Disease - KeratitisCorneal Disease - KeratoconusCorneal Disease - Ulcer(s)Cortical (Central) Vision Impairment (CVI)Diabetic Retinopathy (DR)Dislocated lensDrug / other toxicityEndophthalmitisGlaucoma - Closed Angle GlaucomaGlaucoma - Other TypesGlaucoma - Primary Open Angle Glaucoma (POAG)HemianopiaMacular Disease - ARMD (wet)Macular Disease - ARMD (dry)Macular Disease - Best's diseaseMacular Disease - Leber's AmaurosisMacular Disease - Macular edemaMacular Disease - Macular holeMacular Disease - Stargardt'sMonocularMyopic DegenerationNeurologicNeurologic - NeoplasmNeurologic - StrokeNystagmusOcular burnsOcular traumaOptic Nerve DiseaseOptic Nerve Disease - Optic atrophy (OA)Optic Nerve Disease - Optic nerve hypoplasia (ONH)Optic Nerve Disease - Optic neuritisOptic Nerve Disease - Optic neuropathyParasitic infectionsProsthesisPseudophakiaRetinal detachment (RD)Retinal holeRetinal ischemiaRetinal vasculitisRetinitis pigmentosa (RP)Retinoblastoma (RB)Retinopathy of Prematurity (ROP)StrabismusThyroid Eye Disease (Grave's)UveitisVitreous hemorrhageOther Other Other OS (left eye) OS (left eye) - None -AchromatopsiaAlbinismAmblyopiaAniridiaAnisometropiaAphakiaBlepharospasmBranch Retinal Artery Occlusion (BRAO)Branch Retinal Vein Occlusion (BRVO)CataractCentral Retinal Artery Occlusion (CRAO)Central Retinal Vein Occlusion (CRVO)ChoroiditisColobomaColoboma - Full ThicknessColoboma - IrisColoboma - RetinalCorneal DiseaseCorneal Disease - Corneal DystrophyCorneal Disease - Corneal EdemaCorneal Disease - Corneal Transplant (PKP)Corneal Disease - Fuch's DystrophyCorneal Disease - Herpes KeratitisCorneal Disease - InfectionCorneal Disease - KeratitisCorneal Disease - KeratoconusCorneal Disease - Ulcer(s)Cortical (Central) Vision Impairment (CVI)Diabetic Retinopathy (DR)Dislocated lensDrug / other toxicityEndophthalmitisGlaucoma - Closed Angle GlaucomaGlaucoma - Other TypesGlaucoma - Primary Open Angle Glaucoma (POAG)HemianopiaMacular Disease - ARMD (wet)Macular Disease - ARMD (dry)Macular Disease - Best's diseaseMacular Disease - Leber's AmaurosisMacular Disease - Macular edemaMacular Disease - Macular holeMacular Disease - Stargardt'sMonocularMyopic DegenerationNeurologicNeurologic - NeoplasmNeurologic - StrokeNystagmusOcular burnsOcular traumaOptic Nerve DiseaseOptic Nerve Disease - Optic atrophy (OA)Optic Nerve Disease - Optic nerve hypoplasia (ONH)Optic Nerve Disease - Optic neuritisOptic Nerve Disease - Optic neuropathyParasitic infectionsProsthesisPseudophakiaRetinal detachment (RD)Retinal holeRetinal ischemiaRetinal vasculitisRetinitis pigmentosa (RP)Retinoblastoma (RB)Retinopathy of Prematurity (ROP)StrabismusThyroid Eye Disease (Grave's)UveitisVitreous hemorrhageOther Other Other Secondary cause of vision loss OD (right eye) OD (right eye) - None -AchromatopsiaAlbinismAmblyopiaAniridiaAnisometropiaAphakiaBlepharospasmBranch Retinal Artery Occlusion (BRAO)Branch Retinal Vein Occlusion (BRVO)CataractCentral Retinal Artery Occlusion (CRAO)Central Retinal Vein Occlusion (CRVO)ChoroiditisColobomaColoboma - Full ThicknessColoboma - IrisColoboma - RetinalCorneal DiseaseCorneal Disease - Corneal DystrophyCorneal Disease - Corneal EdemaCorneal Disease - Corneal Transplant (PKP)Corneal Disease - Fuch's DystrophyCorneal Disease - Herpes KeratitisCorneal Disease - InfectionCorneal Disease - KeratitisCorneal Disease - KeratoconusCorneal Disease - Ulcer(s)Cortical (Central) Vision Impairment (CVI)Diabetic Retinopathy (DR)Dislocated lensDrug / other toxicityEndophthalmitisGlaucoma - Closed Angle GlaucomaGlaucoma - Other TypesGlaucoma - Primary Open Angle Glaucoma (POAG)HemianopiaMacular Disease - ARMD (wet)Macular Disease - ARMD (dry)Macular Disease - Best's diseaseMacular Disease - Leber's AmaurosisMacular Disease - Macular edemaMacular Disease - Macular holeMacular Disease - Stargardt'sMonocularMyopic DegenerationNeurologicNeurologic - NeoplasmNeurologic - StrokeNystagmusOcular burnsOcular traumaOptic Nerve DiseaseOptic Nerve Disease - Optic atrophy (OA)Optic Nerve Disease - Optic nerve hypoplasia (ONH)Optic Nerve Disease - Optic neuritisOptic Nerve Disease - Optic neuropathyParasitic infectionsProsthesisPseudophakiaRetinal detachment (RD)Retinal holeRetinal ischemiaRetinal vasculitisRetinitis pigmentosa (RP)Retinoblastoma (RB)Retinopathy of Prematurity (ROP)StrabismusThyroid Eye Disease (Grave's)UveitisVitreous hemorrhageOther Other Other OS (left eye) OS (left eye) - None -AchromatopsiaAlbinismAmblyopiaAniridiaAnisometropiaAphakiaBlepharospasmBranch Retinal Artery Occlusion (BRAO)Branch Retinal Vein Occlusion (BRVO)CataractCentral Retinal Artery Occlusion (CRAO)Central Retinal Vein Occlusion (CRVO)ChoroiditisColobomaColoboma - Full ThicknessColoboma - IrisColoboma - RetinalCorneal DiseaseCorneal Disease - Corneal DystrophyCorneal Disease - Corneal EdemaCorneal Disease - Corneal Transplant (PKP)Corneal Disease - Fuch's DystrophyCorneal Disease - Herpes KeratitisCorneal Disease - InfectionCorneal Disease - KeratitisCorneal Disease - KeratoconusCorneal Disease - Ulcer(s)Cortical (Central) Vision Impairment (CVI)Diabetic Retinopathy (DR)Dislocated lensDrug / other toxicityEndophthalmitisGlaucoma - Closed Angle GlaucomaGlaucoma - Other TypesGlaucoma - Primary Open Angle Glaucoma (POAG)HemianopiaMacular Disease - ARMD (wet)Macular Disease - ARMD (dry)Macular Disease - Best's diseaseMacular Disease - Leber's AmaurosisMacular Disease - Macular edemaMacular Disease - Macular holeMacular Disease - Stargardt'sMonocularMyopic DegenerationNeurologicNeurologic - NeoplasmNeurologic - StrokeNystagmusOcular burnsOcular traumaOptic Nerve DiseaseOptic Nerve Disease - Optic atrophy (OA)Optic Nerve Disease - Optic nerve hypoplasia (ONH)Optic Nerve Disease - Optic neuritisOptic Nerve Disease - Optic neuropathyParasitic infectionsProsthesisPseudophakiaRetinal detachment (RD)Retinal holeRetinal ischemiaRetinal vasculitisRetinitis pigmentosa (RP)Retinoblastoma (RB)Retinopathy of Prematurity (ROP)StrabismusThyroid Eye Disease (Grave's)UveitisVitreous hemorrhageOther Other Other Primary functional reason for referral (e.g., patient struggles to read print) Primary functional reason for referral (e.g., patient struggles to read print) Other medical conditions or limitations (e.g. arthritis, diabetes) Other medical conditions or limitations (e.g. arthritis, diabetes) Referrer information I am an: Ophthalmologist Optometrist Other health care professional First name First name Last name Last name Clinic or office street address Clinic or office street address City City Province or Territory Province or Territory - Select -AlbertaBritish ColumbiaSaskatchewanManitobaOntarioQuebecNew BrunswickNova ScotiaNewfoundland and LabradorPrince Edward IslandNunavutNorthwest TerritoriesYukon Postal code Postal code Doctor's license to practice number Doctor's license to practice number Phone Phone Fax Fax Email Email *Please fill in all mandatory fields before hitting submit. 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