Request for Service Form - CNIB

Request for ServiceCNIB services are available topeople who have difficulty witheveryday activities due to visionloss. Visit us online at cnib.ca.Section AInformation about the person requiring serviceAPPLICANTMr.Mrs.Ms.Other:First Name:Initial:Last Name:Date of Birth • Month:Day:Year:Address:City:Email:Province:Postal Code:Phone Numbers • Day:Evening:Cell:Would you like us to call someone else to arrange appointments with you or to ask forinformation about you?No Yes (*If yes, please complete the “Contact” section below)CONTACTFirst Name:Relationship:Email:Initial:Last Name:Telephone Number:X Signature of applicant or applicant’s guardianDate:Charitable Registration No. 119219459 RR0003I would like to find out more about CNIBservices. I agree that CNIB can ask myhealth care professional for medicalinformation about me. I understand thatCNIB will respect the confidentiality ofmy personal information.continue on reverse

First Name: Last Name: Date of Birth:Section BInformation about referralREFERRAL SOURCEPlease complete this section when you are referring an applicant to CNIB. Ophthalmologist Optometrist Doctor Family Seniors Residence Other: Hospital Community Agency FriendContact Name:Title:Organization: Telephone: ext:Email:Section CEye Information to be completed by a Doctor Normal Hemianopsia Less than 20° diameter both eyes (describe)BESTCORRECTEDACUITYOD:OS:OU:FIELD OF VISIONDISTANCEOther abnormality: (describe)OD:OS:OU:NEARCORRECTIONOD:Add:OS:Add:KNOWN CAUSE OF VISION LOSSPrimary diagnosis: OD:Other eye conditions: OD:Other related health conditions:Comments:OS:OS:Date of examination:Doctor’s Name: Ophthalmologist Optometrist Telephone:Fax:Email:Other: (describe)X Signature:Date:CNIB USE ONLYStatus Y N Date Received:Signature:ICD9 Code: