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Date of Report
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Name
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Date of Birth
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Date(s) of follow up visit(s):
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Send report to
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ABVI OD who referred
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Devices issued
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Areas of service
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Lighting
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Comments
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Appliances marked
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Comments
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Writing aids
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Comments
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Talking Books
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Comments
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Sunglasses
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Comments
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Orientation & mobility
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Comments
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Rehab training
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Comments
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Support group
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Comments
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Additional comments
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Signed by
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Low Vision
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Signed by
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Low Vision
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Supervision statement
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Signed by
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Low Vision Optometrist
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