Vision Rehabilitation Services - Apply for Services — Vision Rehabilitation Services New Zealand NZ - Individual Adjustment Training for persons with vision loss

Apply for Services

Has the patient/client given consent to this referral?

Yes

Name of Person with Disability

First Name

Last Name

Date of Birth

YYYY

Current Disability/Health Condition/Eye Diagnosis/Diabetes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Required Needs/Services

Please indicate patient's current need(s) and concerns (patient's own words)

Relationship to the Person with Disability

I am the Person with Disability

I am a Key Support Person requesting assistance on behalf of the person above

I am a specialist/professional

If you are requesting assistance on behalf of someone else, please provide your own contact details below:

Please include your name, organisation if applicable, and give us some way of contacting you.