Request a service

Anyone can request a service from Guide Dogs for themselves or others using the following form.
Instructions for filling out the form.

Details of person being referred

Please enter the details of the person who will be receiving services from Guide Dogs NSW/ACT



Title
First Name *
Surname *
Email address
Phone (home)
Phone (work)
Phone (mobile)
Street address*
Suburb *
State *
Post code
Country	We accept referrals for people located anywhere within NSW or ACT, Australia. Please DO NOT submit a referral if the person is located outside of these states. We do not provide services outside of Australia.
Date of Birth
Details of referral organisation/person making referral Please fill out this part if you are applying for services on behalf of somebody else, for example a client, patient or relative.
Is Visual Impairment Due To	War Service Vehicle/Work Accident OtherSpecify Other
Referring	I am referring myself I am referring someone else
Your name
Organisation
Email
Phone
Address
Suburb *
State
Postcode
Type of assistance sought Assistance	If known, please give a brief description of the type of assistance sought or the reason for the referral If known, please give a brief description of the type of assistance sought or the reason for the referral
Previous contact	Has the person received services from Guide Dogs in the past: YesNoDon't Know