Thank you for choosing to refer your patient to Vision Loss Rehabilitation Alberta 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 780-482-0017 (Edmonton) or 403-265-5029 (Calgary).
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 email@example.com should you have a problem submitting this form.