Patient Request for Illinois State Eye Exam & Ocular Reports
Please complete the patient information portion of the requested form and be sure to sign the Consent of Parent or Guardian portion. After you have completed the patient information and signed the parent or guardian consent portion of the requested form, please fax to 312.227.9780.
Be sure to include instructions on where you would like the form(s) sent after it has been completed by our Clinical Staff. For example; if you would like for us to fax it to your child’s school, please include the name of the school name, attention and the fax number.
Download the Kindergarten eye exam
Download the State Ocular Report