CLIENT AUTHORIZATION TO RELEASE MEDICAL INFORMATION

First Name

Last Name

Initials

Date you initialed the form

For Eye Doctor or Physician to fill out:

Exam Date

Cause of Visual Impairment

Visual Acuity with Corrective Lenses Right Eye Distance

Visual Acuity without Corrective Lenses Right Eye Distance

Visual Acuity with Corrective Lenses Left Eye Distance

Visual Acuity without Corrective Lenses Left Eye Distance

Visual Acuity with Corrective Lenses Right Eye Near

Visual Acuity without Corrective Lenses Right Eye Near

Visual Acuity with Corrective Lenses Left Eye Near

Visual Acuity without Corrective Lenses Left Eye Near

Is the patient considered legally blind?
Yes
No

The patient will be attending a month-long, independence training program. Classes will run from 8am to 4pm. There will be some walking and standing involved. We will have a nurse on duty part-time. The student will be living and sharing bathrooms with other people.

Are there any concerns we should be aware of?
Yes
No

If Yes, Please Explain?

Examining Physician Name:

Doctor's Initials

Today's Date

Phone