The Chicago Lighthouse
Low Vision Rehabilitation Service

Download the PDF version of the Low Vision Referral Manual

or fill out the Consultation Request Form below

Consultation Request Form
Patient Information
Patient's Name:
Date:
Address:
Phone:
Date of Birth:
E-Mail:
   
Diagnoses (please check all that apply)
ARMD
 OD OS
Glaucoma
 OD OS
Optic Atrophy
 OD OS
Aphikia
 OD OS
Visual Field Loss
 OD OS
specify
Diabetic Retinopathy
OD OS
Retinitis Pigmentosa
 OD OS
Oculocutaneouos
Albinism
 OD OS
Pseudophakia
 OD OS
Other
 OD OS
specify
   
BVA
OD
OS
 
Patient is having difficulty with the following tasks:
Reading printed material
Seeing street or other signs
Seeing television
Seeing checkbook and bills
seeing faces
Seeing in very bright or very dim illumination
Other:
Doctor:
 

 

 
   
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