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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. A new iteration of this website has been launched and this referral form is no longer valid.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.