You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page.
Skip to Main Content
Select Province:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Ontario
Prince Edward Island
Saskatchewan
Yukon
Français
Print
Change Contrast
Text Resize
Toggle navigation
Patients & Families
Health Care Professionals
About Us
Contact Us
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
You are here:
Vision Loss Rehabilitation Saskatchewan
Home
Doctor Referrals
Health Care Professionals
Referrals
Referral Form
Currently selected
Frequently Asked Questions
Page Image
Health Care Professionals Referral Form
Image Caption
Page Content
Thank you for choosing to refer your patient to Vision Loss Rehabilitation Saskatchewan 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 Professionals Referral Form (PDF)
and send it by fax to 306-565-3300 (Regina) or 306-955-6224 (Saskatoon).
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
--Select One--
Ontario
Alberta
British Columbia
Manitoba
Newfoundland and Labrador
New Brunswick
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Quebec
Saskatchewan
Yukon
*Patient's postal code
*CNIB office closest to patient
--Select One--
AB - Calgary
AB - Edmonton
AB - Grande Prairie
AB - Lethbridge
AB - Medicine Hat
AB - Red Deer
BC - Abbotsford
BC - Kamloops
BC - Kelowna
BC - Prince George
BC - Vancouver
BC - Victoria
MB - Brandon
MB - Winnipeg
NB - Bathurst
NB - Fredericton
NB - Moncton
NB - Saint John
NL - Corner Brook
NL - Grand Falls-Windsor
NL - Labrador
NL - St. John's
NS - Halifax
NS - Sydney
NT - Yellowknife
ON - Barrie
ON - Belleville
ON - Brantford
ON - Cornwall
ON - Hamilton
ON - Kingston
ON - London
ON - Mississauga
ON - Newmarket
ON - North Bay
ON - Oshawa
ON - Ottawa
ON - Owen Sound
ON - Peterborough
ON - Sault Ste. Marie
ON - St. Catharines
ON - Sudbury
ON - Timmins
ON - Thunder Bay
ON - Toronto
ON - Waterloo
ON - Windsor
PE - Charlottetown
QC - Montreal
SK - Regina
SK - Saskatoon
*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 CNIB.
--Select One--
Yes
No
Date consent given (YYYY-MM-DD)
Name of person giving consent (if different from patient)
Patient's vision information
Distance VA (best corrected).
OD (right eye)
--Select One--
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/150
20/200
20/400
Counting Fingers
Hand Motion
Light Perception
No Light Perception
Other
Other
OS (left eye)
--Select One--
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/150
20/200
20/400
Counting Fingers
Hand Motion
Light Perception
No Light Perception
Other
Other
OU (both eyes)
--Select One--
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/150
20/200
20/400
Counting Fingers
Hand Motion
Light Perception
No Light Perception
Other
Other
Near VA (best corrected).
OD (right eye)
--Select One--
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/150
20/200
20/400
Counting Fingers
Hand Motion
Light Perception
No Light Perception
Other
Other
OS (left eye)
--Select One--
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/150
20/200
20/400
Counting Fingers
Hand Motion
Light Perception
No Light Perception
Other
Other
OU (both eyes)
--Select One--
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/150
20/200
20/400
Counting Fingers
Hand Motion
Light Perception
No Light Perception
Other
Other
Rx
OD (right eye)
Add
Rx
OS (left eye)
Add
Current correction is the same as the Rx for both OD and OS
Current Correction - OD (right eye)
Add
Current Correction - OS (left eye)
Add
Visual field
--Select One--
Normal
Abnormal
Describe field loss - OD (right eye)
Visual field in degrees
--Select One--
>150
150-121
120-81
80-61
60-41
40-21
20-11
10-6
5-1
Field loss description
--Select One--
Hemianopsia - Bitemporal
Hemianopsia - Binasal
Hemianopsia - Homonymous (Right)
Hemianopsia - Homonymous (Left)
Hemianopsia - Quadrantanopsia (Upper Left)
Hemianopsia - Quadrantanopsia (Upper Right)
Hemianopsia - Quadrantanopsia (Bottom Left)
Hemianopsia - Quadrantanopsia (Bottom Right)
Central Scotoma
Paracentral Scotoma
Peripheral Scotoma
Hemianopic Scotoma
Describe field loss - OS (left eye)
Visual field in degrees
--Select One--
>150
150-121
120-81
80-61
60-41
40-21
20-11
10-6
5-1
Field loss description
--Select One--
Hemianopsia - Bitemporal
Hemianopsia - Binasal
Hemianopsia - Homonymous (Right)
Hemianopsia - Homonymous (Left)
Hemianopsia - Quadrantanopsia (Upper Left)
Hemianopsia - Quadrantanopsia (Upper Right)
Hemianopsia - Quadrantanopsia (Bottom Left)
Hemianopsia - Quadrantanopsia (Bottom Right)
Central Scotoma
Paracentral Scotoma
Peripheral Scotoma
Hemianopic Scotoma
Primary cause of vision loss
OD (right eye)
--Select One--
Achromatopsia
Albinism
Amblyopia
Aniridia
Anisometropia
Aphakia
Blepharospasm
Branch Retinal Artery Occlusion (BRAO)
Branch Retinal Vein Occlusion (BRVO)
Cataract
Central Retinal Artery Occlusion (CRAO)
Central Retinal Vein Occlusion (CRVO)
Choroiditis
Coloboma
Coloboma - Full Thickness
Coloboma - Iris
Coloboma - Retinal
Corneal Disease
Corneal Disease - Corneal Dystrophy
Corneal Disease - Corneal Edema
Corneal Disease - Corneal Transplant (PKP)
Corneal Disease - Fuch's Dystrophy
Corneal Disease - Herpes Keratitis
Corneal Disease - Infection
Corneal Disease - Keratitis
Corneal Disease - Keratoconus
Corneal Disease - Ulcer(s)
Cortical (Central) Vision Impairment (CVI)
Diabetic Retinopathy (DR)
Dislocated lens
Drug / other toxicity
Endophthalmitis
Glaucoma - Closed Angle Glaucoma
Glaucoma - Other Types
Glaucoma - Primary Open Angle Glaucoma (POAG)
Hemianopia
Macular Disease - ARMD (wet)
Macular Disease - ARMD (dry)
Macular Disease - Best's disease
Macular Disease - Leber's Amaurosis
Macular Disease - Macular edema
Macular Disease - Macular hole
Macular Disease - Stargardt's
Monocular
Myopic Degeneration
Neurologic
Neurologic - Neoplasm
Neurologic - Stroke
Nystagmus
Ocular burns
Ocular trauma
Optic Nerve Disease
Optic Nerve Disease - Optic atrophy (OA)
Optic Nerve Disease - Optic nerve hypoplasia (ONH)
Optic Nerve Disease - Optic neuritis
Optic Nerve Disease - Optic neuropathy
Parasitic infections
Prosthesis
Pseudophakia
Retinal detachment (RD)
Retinal hole
Retinal ischemia
Retinal vasculitis
Retinitis pigmentosa (RP)
Retinoblastoma (RB)
Retinopathy of Prematurity (ROP)
Strabismus
Thyroid Eye Disease (Grave's)
Uveitis
Vitreous hemorrhage
Other
Other
OS (left eye)
--Select One--
Achromatopsia
Albinism
Amblyopia
Aniridia
Anisometropia
Aphakia
Blepharospasm
Branch Retinal Artery Occlusion (BRAO)
Branch Retinal Vein Occlusion (BRVO)
Cataract
Central Retinal Artery Occlusion (CRAO)
Central Retinal Vein Occlusion (CRVO)
Choroiditis
Coloboma
Coloboma - Full Thickness
Coloboma - Iris
Coloboma - Retinal
Corneal Disease
Corneal Disease - Corneal Dystrophy
Corneal Disease - Corneal Edema
Corneal Disease - Corneal Transplant (PKP)
Corneal Disease - Fuch's Dystrophy
Corneal Disease - Herpes Keratitis
Corneal Disease - Infection
Corneal Disease - Keratitis
Corneal Disease - Keratoconus
Corneal Disease - Ulcer(s)
Cortical (Central) Vision Impairment (CVI)
Diabetic Retinopathy (DR)
Dislocated lens
Drug / other toxicity
Endophthalmitis
Glaucoma - Closed Angle Glaucoma
Glaucoma - Other Types
Glaucoma - Primary Open Angle Glaucoma (POAG)
Hemianopia
Macular Disease - ARMD (wet)
Macular Disease - ARMD (dry)
Macular Disease - Best's disease
Macular Disease - Leber's Amaurosis
Macular Disease - Macular edema
Macular Disease - Macular hole
Macular Disease - Stargardt's
Monocular
Myopic Degeneration
Neurologic
Neurologic - Neoplasm
Neurologic - Stroke
Nystagmus
Ocular burns
Ocular trauma
Optic Nerve Disease
Optic Nerve Disease - Optic atrophy (OA)
Optic Nerve Disease - Optic nerve hypoplasia (ONH)
Optic Nerve Disease - Optic neuritis
Optic Nerve Disease - Optic neuropathy
Parasitic infections
Prosthesis
Pseudophakia
Retinal detachment (RD)
Retinal hole
Retinal ischemia
Retinal vasculitis
Retinitis pigmentosa (RP)
Retinoblastoma (RB)
Retinopathy of Prematurity (ROP)
Strabismus
Thyroid Eye Disease (Grave's)
Uveitis
Vitreous hemorrhage
Other
Other
Secondary cause of vision loss
OD (right eye)
--Select One--
Achromatopsia
Albinism
Amblyopia
Aniridia
Anisometropia
Aphakia
Blepharospasm
Branch Retinal Artery Occlusion (BRAO)
Branch Retinal Vein Occlusion (BRVO)
Cataract
Central Retinal Artery Occlusion (CRAO)
Central Retinal Vein Occlusion (CRVO)
Choroiditis
Coloboma
Coloboma - Full Thickness
Coloboma - Iris
Coloboma - Retinal
Corneal Disease
Corneal Disease - Corneal Dystrophy
Corneal Disease - Corneal Edema
Corneal Disease - Corneal Transplant (PKP)
Corneal Disease - Fuch's Dystrophy
Corneal Disease - Herpes Keratitis
Corneal Disease - Infection
Corneal Disease - Keratitis
Corneal Disease - Keratoconus
Corneal Disease - Ulcer(s)
Cortical (Central) Vision Impairment (CVI)
Diabetic Retinopathy (DR)
Dislocated lens
Drug / other toxicity
Endophthalmitis
Glaucoma - Closed Angle Glaucoma
Glaucoma - Other Types
Glaucoma - Primary Open Angle Glaucoma (POAG)
Hemianopia
Macular Disease - ARMD (wet)
Macular Disease - ARMD (dry)
Macular Disease - Best's disease
Macular Disease - Leber's Amaurosis
Macular Disease - Macular edema
Macular Disease - Macular hole
Macular Disease - Stargardt's
Monocular
Myopic Degeneration
Neurologic
Neurologic - Neoplasm
Neurologic - Stroke
Nystagmus
Ocular burns
Ocular trauma
Optic Nerve Disease
Optic Nerve Disease - Optic atrophy (OA)
Optic Nerve Disease - Optic nerve hypoplasia (ONH)
Optic Nerve Disease - Optic neuritis
Optic Nerve Disease - Optic neuropathy
Parasitic infections
Prosthesis
Pseudophakia
Retinal detachment (RD)
Retinal hole
Retinal ischemia
Retinal vasculitis
Retinitis pigmentosa (RP)
Retinoblastoma (RB)
Retinopathy of Prematurity (ROP)
Strabismus
Thyroid Eye Disease (Grave's)
Uveitis
Vitreous hemorrhage
Other
Other
OS (left eye)
--Select One--
Achromatopsia
Albinism
Amblyopia
Aniridia
Anisometropia
Aphakia
Blepharospasm
Branch Retinal Artery Occlusion (BRAO)
Branch Retinal Vein Occlusion (BRVO)
Cataract
Central Retinal Artery Occlusion (CRAO)
Central Retinal Vein Occlusion (CRVO)
Choroiditis
Coloboma
Coloboma - Full Thickness
Coloboma - Iris
Coloboma - Retinal
Corneal Disease
Corneal Disease - Corneal Dystrophy
Corneal Disease - Corneal Edema
Corneal Disease - Corneal Transplant (PKP)
Corneal Disease - Fuch's Dystrophy
Corneal Disease - Herpes Keratitis
Corneal Disease - Infection
Corneal Disease - Keratitis
Corneal Disease - Keratoconus
Corneal Disease - Ulcer(s)
Cortical (Central) Vision Impairment (CVI)
Diabetic Retinopathy (DR)
Dislocated lens
Drug / other toxicity
Endophthalmitis
Glaucoma - Closed Angle Glaucoma
Glaucoma - Other Types
Glaucoma - Primary Open Angle Glaucoma (POAG)
Hemianopia
Macular Disease - ARMD (wet)
Macular Disease - ARMD (dry)
Macular Disease - Best's disease
Macular Disease - Leber's Amaurosis
Macular Disease - Macular edema
Macular Disease - Macular hole
Macular Disease - Stargardt's
Monocular
Myopic Degeneration
Neurologic
Neurologic - Neoplasm
Neurologic - Stroke
Nystagmus
Ocular burns
Ocular trauma
Optic Nerve Disease
Optic Nerve Disease - Optic atrophy (OA)
Optic Nerve Disease - Optic nerve hypoplasia (ONH)
Optic Nerve Disease - Optic neuritis
Optic Nerve Disease - Optic neuropathy
Parasitic infections
Prosthesis
Pseudophakia
Retinal detachment (RD)
Retinal hole
Retinal ischemia
Retinal vasculitis
Retinitis pigmentosa (RP)
Retinoblastoma (RB)
Retinopathy of Prematurity (ROP)
Strabismus
Thyroid Eye Disease (Grave's)
Uveitis
Vitreous hemorrhage
Other
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:
Ophthalmologist
Optometrist
Other health care professional
*Please specify health care profession
*First name
*Last name
*Clinic or office street address
*City
*Province or Territory
--Select One--
Ontario
Alberta
British Columbia
Manitoba
Newfoundland and Labrador
New Brunswick
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Quebec
Saskatchewan
Yukon
*Postal code
Doctor's license to practice number
*Phone
Fax
Email
*Please fill in all mandatory fields before hitting submit.