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

Child Information


Doctor Information

Guardian Information

Additional Options
The eye being patched will be the eye NOT affected by Amblyopia
  * Quantities are limited

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.