Needed before clinic appointment by qI8D3u


									                            Pre-Clinic Instructional Checklist
KY School for the Blind     1867 Frankfort Avenue       Louisville, KY    40206       (502) 897-1583

 Student Name: ____________________________                   District: _______________________

 Thank you for your interest in the Kentucky School for the Blind Low Vision Clinic. Because we offer
 educationally oriented vision services, there are several things that need to be completed before a
 student can be scheduled:

       ____ A copy of the signed evaluation plan form from the ARC indicating a clinical low vision
       ____ A copy of the current Functional Vision Learning Media Assessment (within 3 years)
       ____ A copy of current medical information from the primary eye care provider (The doctor
            requires medical information to be within one year)
       ____ Referral/Low Vision Concern Form

 Please return this form along with the necessary paperwork requested above so that we may
 schedule a Clinical Low Vision evaluation. Keep a copy for your file as well. Mail to Meg Stone
 at the address at the top of the page or Fax to: 502-897-8737.

 Once the clinic appointment has been scheduled the parents will receive the following:

              Low Vision History form to be completed by the student or parent
              Permission Form/Release of Records
              Letter with appointment date and time
              Directions to clinic location
              Article: Preparing Your Student for a Clinical Low Vision Evaluation

       The Low Vision History form and Permission/Release of Records form should be returned in
       the envelope provided in your packet.

 Teachers: Remind your students and parents to bring the following to the clinic:

       ____ Glasses, low vision devices, reading material, class book, sample of handwriting
       ____ Questions for doctors

 Please check other items of interest:
       ____ Tour of campus
       ____ Center-based Program information
       ____ Short Term Program information
       ____ Summer Program information
       ____ Overnight lodging in the dorm
       ____ Parent Resource Center

 If you have any questions please contact Meg Stone (ext. 219) or Beth Bohannon (ext. 256) at the
 phone number listed at the top of the page.

                                                                                  Revised date 07/12

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