Kalamazoo County Health and Community Services - Hearing & Vision Screening Program, Preschool Screening Appointment Request Form

Department Home

Hearing / Vision Home

Adopted Rules

Our Customers

Frequently Asked Questions

Appointment Request Form

Information

Related Links

Just For Kids

Requirements/Procedures

Health and Community Services

Hearing & Vision Screening Program

PRESCHOOL SCREENING APPOINTMENT REQUEST FORM

NOTE: Michigan Law requires that children entering school be tested for vision problems prior to enrollment. Preschool screening is recommended beginning at age three.

To request a Hearing and Vision Screening Appointment for your child, fill out and submit this Preschool Hearing and Vision Appointment Request form. The completed form can also be printed and faxed to (269) 373-5168. Once we receive the completed form, a Hearing and Vision Technician will contact you to schedule an appointment.

Any personal information that you provide will be kept highly confidential. None of the information will be used for any other reason than to contact you as requested.

Child's Last Name	Child's First Name	Child's Birth Date:
Parent's/Guardian's Name:	Complete Mailing Address
Telephone Number(s)	E-Mail Address
School District
BRIEF EYE HISTORY
1. Has your child ever been examined by an eye doctor? Yes No
If Yes, when?
2. When your child is ill or tired, do eyes appear crossed or one eye wander when looking at an object? Yes No

NOTE: This is NOT a forum for advertising products. Any e-mails or form data sent for this purpose will be immediately discarded!

E-Mail Hearing & Vision Screening Program

Health and Community Services programs are open to all without regard
to race, color, national origin, sex or disability.

Links to external sites do not constitute endorsements by Kalamazoo County.