School/Work Release Form
Patient Name
First Name
Last Name
Date of Appointment
-
Month
-
Day
Year
Date
Location of Appointment
Westerville Office
Johnstown Office
The Solution Center
Lewis Center Office
Time of Appointment
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Patient Email (the School/Work Excuse will be sent to this email address)
example@example.com
Patient was seen for the following care:
Comprehensive Eye Exam
Contact Lens Related Office Visit
Eye Health Related Office Visit
Eyeglass Problem
Special Testing
Vision Therapy Session
Vision Therapy Re-evaluation
This patient has been dilated, and instructed on the normal and abnormal symptoms of this procedure. This patient may continue to be sensitive to light and may experience minor blurred vision for approximately 6-8 hours after their appointment.
Yes, this patient has been dilated.
No, this patient was not dilated.
This patient may:
Return to work/school without restrictions
Return to work/school without restrictions after their scheduled follow up visit listed below
Return to work/school with the restrictions listed below
NOT return to work/school until the date listed below
Additional follow ups, restrictions, and comments regarding this patient's ability to return to school/work:
Office Staff Signature
Submit
Should be Empty: