Corporate Solutions> Vision Australia Referral Form

Low vision patients are at a greater risk of falls, depression and social exclusion¹.

Vision Australia are the specialists in low vision support and your partners in the circle of care.

If you have any concerns about the quality of life of your low vision patient simply refer to Vision Australia for a free assessment or call (02) 9053 4585 for more information.

Patient Information

Patient's full name *

Patients email *

Patient's phone number *

Patient's Post code *

Clinic Information

Doctor's full name *

Clinic name *

Clinic post code *

Clinic phone number *

Preferred contact email *

Reason for referral *

Other information

Linking Factsheet *

My patient has consented to being contacted by Vision Australia

The clinic contact information you have provided will not be used for any communication, it will only be used to validate the clinic *

I understand

¹Clear Focus – The Economic Impact of Vision Loss in Australia in 2009, Vision 2020 (page 10)