Visual Impairment Form
304-558-1675 voice/tty - Toll Free 866-461-3578 voice/tty


Complete
this form only if you are requesting the
 Low-Vision TTY or Amplified Phone

 

NAME: _____________________________________________________________
   
ADDRESS: _____________________________________________________________
   
  _____________________________________________________________

                                                               

This section to be filled out by an Optometrist

Optometrist: ___________________________________________________________
   
Address: ___________________________________________________________
   
  ___________________________________________________________
   
Phone: ___________________________________________________________
   
Physician's Signature: _____________________________________________________
   
Patient has:  low vision____   no vision____   include copy of visual examination

   
Comments: ___________________________________________________________
   
______________________________________________________________________
   
______________________________________________________________________
   
______________________________________________________________________

 

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