Vision Impairment Adaptive Services Request

Vision Impairment Adaptive Services Request — Form Fields

This healthcare template includes 13 fields. Patients with vision impairment request adaptive services such as large-print materials, audio support, or mobility assistance. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Contact Email (email, required)
• Phone Number (text, required)
• Vision Impairment Level (dropdown selection, required) — options: Low Vision, Legal Blindness, Total Blindness
• Primary Cause of Vision Impairment (dropdown selection, required) — options: Macular Degeneration, Glaucoma, Diabetic Retinopathy, Congenital, Injury, Other
• Large-print materials needed (checkboxes, optional)
• Braille materials needed (checkboxes, optional)
• Audio assistance requested (checkboxes, optional)
• Sighted guide assistance needed (checkboxes, optional)
• Screen reader compatible patient portal access (checkboxes, optional)
• Referring Eye Care Provider (text, optional)
• Additional accommodation requests (long text, optional)