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this form.

Refer a patient

Taking a few minutes to refer your patients to Vision Australia can change a life. Our dedicated allied health team will support you in the circle of care to ensure the best outcomes for your low vision or blind patients.

Fields marked with * are mandatory.

Referring professional details

First name

Last name

Referrer profession

Email address

Mobile

Business name

Business or company name.

Location/Branch

Location or branch of the company if relevant.

Business phone

No spaces, area code if landline.

Street address

Suburb

State

Postcode

Details of the person you are referring

Consent

This person (or a parent/guardian for a child) has given consent for this referral. Vision Australia needs consent to ensure privacy of our clients.

Person's first name

Person's last name

Person's contact number

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

Person's email address

Person's date of birth

dd/mm/yyyy.

Person's street address

Person's suburb

Person's state

Person's postcode

Need for interpreter

Person's preferred language

Is the person of Aboriginal and/or Torres Strait Islander origin?

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

Does this person have a primary contact other than themselves? (please select one)

YesNo

Primary contact's first name

Primary contact's last name

Primary contact's relationship to person

Primary contact's contact number

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

Primary contact's email

Referral details

Reason for referral

Any other relevant information about this person (health/wellbeing, eye condition, etc.)?

Does this person's mental health, mobility or current life circumstance classify them as a high priority?

Please check if 'Yes'

Please attach a recent eye report or other documents. An eye report will expediate our processing of your referral.

Primary eye condition (up to 255 characters)

Confirmation

Please review all information before submitting and bookmark this page.

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.

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