Request services for others

Fields marked with * are mandatory.

Before we begin

Complete this form if you are requesting services for a family member, friend, or as a carer of someone who is 18 or older. You will be the primary contact person for this enquiry.



Be sure to obtain permission from the person before completing this form. Providing us their information confirms their agreement to discuss services and share personal information with Vision Australia. We handle information in accordance with our privacy policy.

Request services for others

Fields marked with * are mandatory.

Step 1 of 4

Step 1 of 2

Your details





Enter 10 digits without spaces starting with ‘0’ for mobile or phone with area code

If you do not have an email address, enter the email of a family member or carer, or call us on 1300 847 466.

Contact preferences



Request services for others

Fields marked with * are mandatory.

Step 2 of 4

Step 2 of 2

About the person

Answer the following questions about the person for who you are completing this form.

Their details




If you are under 18, a parent or guardian must complete a Request services for my child form on your behalf.


We ask this question to provide culturally appropriate, prioritised access to programs and services, and to improve overall health outcomes.

Their needs



By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our Privacy Policy. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support.

Request services for others

Fields marked with * are mandatory.

Step 3 of 4

Their vision




Request services for others

Fields marked with * are mandatory.

Step 4 of 4

Funding status

If the person is eligible for a funding source or government support (such as NDIS or My Aged Care) they need to access it to receive services from us. Alternatively, they can choose to speak to us about other options to access services.




Their needs


By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our Privacy Policy. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support.