Ohio Amblyope Services Request Form
Ohio Amblyope Registry (OAR) Services Request Form
The Ohio Amblyope services are funded by the Save Our Sight Fund and are only available to Ohio residents diagnosed with Amblyopia (until 18 year of age).
*
Indicates required fields
Requester Information
Your First Name
Your Last Name
Your Phone
Child Information
Child First Name
Child Middle Name
Child Last Name
Child's First Request for Services?
Child Date of Birth
Child Date of Diagnosis
Child's Gender
Child's Ethnicity
Child's Race(s) - please check all that apply
*
Caucasian/White
African-American
American Indian or Alaska Native
Asian
Native Hawaiian/Pacific Islander
Other
Unknown
Doctor Information
Dr. Type
Dr. First Name
Dr. Last Name
Guardian Information
Guardian First Name
Guardian Middle Name
Guardian Last Name
Guardian Relationship
Guardian Mailing Address
Guardian Mailing City
Guardian Mailing State
Guardian Mailing Zip
Guardian Mailing County
Guardian Email
Confirm Email
Guardian Phone
Preferred Contact Method
Additional Options
Which service(s) you are requesting
Patching Poster
Parent Resource Packet
Patching Storybook
Patches
†
Which eye is being patched
Doctor prescribed patch type
Eye Patch Design
Eye Patch Supply
†
The eye being patched will be the eye NOT affected by Amblyopia
* Quantities are limited
Submit
Upon registration you are automatically enrolled to receive additional support called case management. You will receive important and helpful emails or phone calls to provide continued support through the patching process. If you do not want this additional support, please contact us at 877-808-2422 or amblyopia@nationwidechildrens.org. You will need to leave your child’s first and last name along with their date of birth.
