At-Home Vision Check and Cover-Test Video Results

At-Home Vision Check and Cover-Test Video Results

After reading the instructions on our website, please complete and upload the results of your at-home vision check and cover-test video
Note: Hitting Enter will submit your form. Please use the tab bar or your mouse to toggle between questions.
Patient Name

First NameLast Name
Please record your child's vision test results below:
Which type of chart was used?

Snellen letter chartLea picture chartHOTV chart
Was this test was done with or without glasses?

With glassesWithout glasses
Please upload your cover-test video results:

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Please upload any relevant photos.

Browse Files

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Should be Empty: