Low Vision Collaboration Clinic + Forms

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Low Vision Collaboration Clinic + Forms

A Low Vision Collaboration Clinic+ (LVCC+)is for infants, toddlers or school-aged children who have alternative communication and complex needs.

Information needed for Low Vision Collaboration Clinic+ are: When emailing documents, please send individually and put clinic date in the subject line.

Consent Form for Onsite Clinic OR Consent Form for Virtual Consultation
Contact Information Form (Use Child/Student’s Legal Name);
Child-Student Eye Doctor's Information
Child Family History Form
Release form from Dr. Linda Lawrence's office (only needed for Dr. Lawrence's clinics) Do not write KanLovKids on it
Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, Medical Records and Orientation and Mobility Report
Media Consent Form (not needed for virtual clinics)

Please email documents (1-7) listed to Erin Kelly ekelly@kssdb.org 913-305-3061

AND Judy Imber jimber@kssdb.org 913-645-5843

ALL DOCUMENTS ARE DUE ONE MONTH BEFORE CLINIC DATE (be sure to indicate if ASL or Spanish interpreter is needed)
BRING SUPPORTED SEATING EQUIPMENT AND TRAVEL OR WHEELCHAIR TRAYS, ALONG WITH TOYS OR OBJECTS THE CHILD PREFERS.