Ophthalmic Referral Form

Make an Ophthalmic Referral

To make an ophthalmic referral please tell us about your patient by completing the form below. There is the option to attach documents such as a clinic letter or visual field results at the end of the form 

Important note: We can still proceed with your referral, however, will need more information from your patient. For example, Blind Low Vision NZ will need to be notified of the date of the accident, type of injury and if possible of their ACC claim number if already known. The person you are referring additionally needs to be referred to ACC in order to make a claim.

What are your patient's details?

Please type in your patient's personal details as they appear on official documents. This helps us to prevent the creation of duplicate records in case they were already registered with us.

Personal Details

If you cannot find a certain ethnicity in the picklist, then please select "Other".

Contact Details

What are your details?

Ophthalmic Details

To complete your referral, we need to know a bit more about your patient's eye health including:
  • Their best corrected visual acuity in each eye
  • Visual field for each eye if appropriate
  • Your diagnosis for each eye
  • Their prognosis
  • Any additional info you would like to mention

Best corrected visual acuity

Field of Vision


Please specify your patient's diagnosis for each eye. You can select common eye conditions in the picklists below. If you cannot find the eye condition of your patient, please select "Other disorders of the eye" and specify in the provided text field.

Additional Information

Before you submit your referral...

Attach any supporting documentation using the button below:

Important note: We can still proceed with your referral, however, could you please provide the reason why this request has not been discussed with your patient? Please note, we will be contacting the person being referred to obtain additional information and confirm their request for service.

Rights & Privacy