Request a service - Guide Dogs Victoria

Who is making the referral?

Referrer Details

First Name

Last Name

Organisation

Your Position

Your relationship to person you are referring

Mobile or Landline

For landlines please add area code, please ensure that there are no spaces between the numbers.

Email

Do you have consent to make this referral?

Client Details:

Title

First Name

Last Name

Gender

Date of Birth

Please enter Date of Birth in DD/MM/YYYY Format Ex: 25/12/1980 for 25th of December 1980.

Does the person identify as Aboriginal or Torres Strait Islander?

Is an Interpreter required?

Please state the Language

Mobile or Landline

For Landline please include area code, please ensure that there are no spaces between the numbers.

Email:

Where did you hear about us?

Address:

Street

Suburb/City

Postcode

State

What assistance do you require from Guide Dogs Victoria?

Please provide information about their vision

What support would they like from Guide Dogs Victoria?

Do you have additional medical information you would like to provide?

E.g. Medical Documents, Vision Condition Information

Additional Details

Do you have any relevant medical documents to upload?

Please select to upload relevant documents

Vision ReportDischarge SummaryOther Medical informationMedical Action Plans

Upload Vision Report

Upload Discharge Summary

Upload Other Medical Information

Upload Medical Action Plans

Do you receive funding from:

Do they receive funding from:

Other - Please specify

Provider Number

Please provide details of their vision status:

Date of diagnosis

Please enter Date in DD/MM/YYYY Format

Does the person use a mobility aid?

Please provide details

Is the vision status related to an Acquired Brain Injury?

Site of lesion (If applicable):

Cognitive impairment (If applicable):

Please provide details:

Is the person currently involved in therapy?

What therapy is the client currently involved in?

Please provide information about your vision

Need assistance with this form?

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Guide Dogs Victoria