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Referrals - Banner
Health Care Professionals Referral Form

​​​Thank you for choosing to refer your patient to Vision Loss Rehabilitation Newfoundland and Labrador 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 Healt​​h Care Professionals Referral Form (PDF)​​ and send it by fax to 709-754-2018.

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@v​lrehab.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.