Medical Eye Report | VISIONS/Services for the Blind and Visually Impaired

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VISIONS/Services for the Blind and Visually Impaired

Man with cane

MEDICAL EYE REPORT FORM

Please print out this page or download our form and fax completed form to 212-219-4078 to begin vision rehabilitation services:

Patient Name	Date of Birth	Social Security #
Address	Apt. #	Home Telephone #
City	State	Zip Code	Gender

Parent/Guardian Name
Address

Date of last eye exam:_____________________

Findings of eye exam	Right Eye (OD)	Left Eye (OS)
Diagnosis :
Corrected Acuity:	20/________	20/________
Field:	There is no apparent field restriction.	There is no apparent field restriction.
	There is a field restriction (describe):	There is a field restriction (describe):
	The visual field is restricted to 20° or less	The visual field is restricted to 20° or less

Prognosis:	Stable Progressive Improving
Recommended treatment(s): ______________________________ _____________________________________________________
______________________ Signature of Examiner	________ Date	___________________ Print name of Examiner
Address: _______________________ _______________________________	Phone #:_____________
Submitter:_________________________ (If different from above.)

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