Register as a new client with Blind Low Vision NZ

Is your eye condition the result of an accident?

YesNo

Is their eye condition the result of an accident?

YesNo

Important note

We can still proceed with your request for services, however, need more information from you. For example, Blind Low Vision NZ will need to be notified of the date of the accident, type of injury and if possible your ACC claim number and ACC Case Manager details. If you already know these details, please enter them into the fields below, otherwise, please contact your GP or eye health specialist to make a claim with ACC.

I understand

Important note

We can still proceed with your request for services, however, need more information from the person you are referring. For example, Blind Low Vision NZ will need to be notified of the date of the accident, type of injury and if possible their ACC claim number and ACC Case Manager details. If you already know these details, please enter them into the fields below, otherwise, the person you are referring needs to contact their GP or eye health specialist to make a claim with ACC.

I understand

Date of Accident

Type of injury

ACC Claim Number

ACC Case Manager's Name

ACC Case Manager's contact details (phone or email)

Additional details

The following information is required for the Ministry of Health and helps us check eligibility for services, what means of funding is available and which services may be helpful.

NHI Number (if known)

Gender

Primary Ethnicity

If you cannot find your ethnicity in the picklist, then please select "Other" and specify in the next field "Other Ethnicity".

Other Ethnicity

Are you a New Zealand Citizen / Permanent Resident?

YesNo

Are you employed?

YesNo

Do you have access to the internet at home?

YesNo

The name of the person you are referring.

Additional details

The following information is required for the Ministry of Health and helps us check eligibility for services, what means of funding is available and which services may be helpful.

What is their NHI Number? (if known)

Date of Birth

Gender

Primary Ethnicity

If you cannot find your ethnicity in the picklist, then please select "Other" and specify in the next field "Other Ethnicity".

Other Ethnicity

Are they a New Zealand citizen / permanent resident?

YesNo

Are they employed?

YesNo

Do they have access to the internet at home?

YesNo

Street Address

Suburb

City

Post Code

Postal address

Street Address / PO Box

Suburb

City

Post Code

Street Address

Suburb

City

Post Code

Postal address

Street Address / PO Box

Suburb

City

Post Code

In order to process your request for services, we need some information about your eye health, including your most recent eye report and details of your eye health practitioner. Please provide as much information as you're able to.

If you know the contact information of the eye health practitioner for the person you're referring, we may contact them for information regarding their condition.

Please upload the eye report by selecting "Choose File" below. Alternatively, you can email it through as an attachment to registrations@blindlowvision.org.nz

Attach Files

Title

First Name

Last Name

Known as

What is your relationship to this person?

What is their call preference?

Home phone number

Mobile phone number

Work phone number

The name and contact details of the referring person.

Title

First Name

Last Name

Known as

What is your relationship to the person you are referring?

What is your call preference?

Home phone

Mobile phone

Work phone

Community committees

In many areas we have community based committees, local support groups and other contacts who run a variety of activities for clients in their area.

Do you agree for us to share contact details with local community committee groups run and overseen by Blind Low Vision NZ?

YesNo

Peer support groups

There are Blind Low Vision NZ endorsed organisations that represent the interests of people who are blind/deafblind or have low vision. They offer peer support, advocacy and social activities.

Do you agree for us to share contact details with peer support groups that represent the interests of people who are blind/deafblind or have low vision?

YesNo