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Referral packets

To refer students to the CSB Low Vision Clinic, please complete the following documents and attach them to the eye care professional’s report and the IEP cover sheet.  Once all of the elements are collected, please send them as a package.

            ____Low Vision Clinic Referral Application
            ____Parent Permission Form/Photographic Release Form
            ____Patient Information Form
            ____Vision Report from eye care professional
            ____IEP Cover Sheet, noting that the student qualifies for vision service

Referral Application

Parent Permission

Photographic Release

Patient Information