Alberta uses this report when a driver may not have met the basic vision standard at a licence vision screening. An optometrist or ophthalmologist examines the driver and records visual acuity and formal binocular visual field results, and the results go to Alberta's Driver Fitness and Monitoring. The form is an encrypted fillable PDF that must be opened in Adobe Reader.
An optometrist or ophthalmologist completes the examination findings and signs as examiner. The client, the driver being assessed, signs the authorization section.
Download the current version from the source each time; forms change without notice.
Visual Referral Report
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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A vision specialist: an optometrist or an ophthalmologist. The specialist examines the driver, records visual acuity and formal binocular visual field results, and signs as examiner, while the driver signs the authorization on the form. The completed report goes back to the client.
Formal binocular visual field results. Alberta asks for a full-field 120-point screening test, or a 150-point test for drivers of emergency vehicles. Visual acuity is recorded as well, and both form part of the examination findings the specialist signs.
It is an encrypted XFA form. Alberta's form says it cannot be opened in a web browser, and it does not work on mobile devices. Download it and open it in Adobe Reader on a computer to fill it in, print it and sign it.