Eye Doctor's Note

Patient Name:                                                   
Date of Birth:            /            /           

This is to confirm that the above-named patient was evaluated on            /            /            for an eye examination and diagnosed with                                                   . The patient may require accommodations or restrictions as follows:

Recommendations:

                                                                                                                                                                                                                                                                                                                                                              

For further verification, please contact my office.

Doctor’s Name:                                                   
Medical Facility:                                                   
Contact:                                                   

Date:            /            /