Register An Amblyopic Child

Child with glasses

In order to register an amblyopic child and receive free material as list below, the child must have been diagnosed with amblyopia by an eye doctor. Ideally, please talk with the child's eye doctor before registering with the Ohio Amblyope Registry. You can also obtain a registration form from your eye doctor. Registration is open to any amblyopic child up to 18 years of age who lives in the State of Ohio.

What the parents receive for free once the amblyopic child is registered:

1. Brochures

	Amblyopia (lazy eye)
	Strabismus (misaligned eyes)
	First Aid for Eye Emergencies
	Don’t Play Games with Your Eyes
	Play it Safe
	Your Child’s Sight
	Signs of Possible Eye Trouble in Children
	Common Eye Problems
	Semiannual Newsletter "Lazy Eye News"

2. If your child is being patched for amblyopia, s/he will receive 2 large free boxes of eye patches, a $45.00 value!

3. If your child is being patched for amblyopia, s/he will also receive two (2) free cloth patches that cover one side of glasses, available upon request and with the approval of your child's eye doctor. Please specify the eye being patched and your child's gender.

4. If your child is being patched for amblyopia and if s/he is between the ages of 3 and 8 years, you will receive the Eye Patch poster. "After a successful day of patching, your child can remove his/her patch and apply it to the poster. You can then hang the completed poster in your child's room." Each poster holds up to 50 patches and measures 16" x 20". You will also receive a newsletter, Lazy eye News, about tips and techniques for promoting compliance and professional advice from optometrists, ophthalmologists and orthoptists as well as other important information about lazy eye.

5. You will also receive a Free Patches application form. If family income is less than 2 times the poverty level for family size the family can qualify to receive up to 15 boxes of free patches, a $337.50 value!

All free materials are paid for by the Save Our Sight Fund for Children, which receives voluntary donations via the check-off box on Ohio license plate renewal forms. Support the Save Our Sight Fund for Children the next time you renew your license plate.

Privacy Statement

Regarding registering an amblyopic child, all information will remain strictly confidential. The parent's and child's name, address and all other personal information will only be used to send information to you or your child's eye doctor. We will not release your personal information to anyone else for any reason. All registration information is removed from the internet and placed on a secured computer that does not have internet capability. Any reports we produce will use summary data only with no names, addresses or personal information released, as mandated by the Ohio Department of Health.

Amblyopic Child Registration Form

Child's Name: First

Last

Child's Gender:

Parent's Name: First

Last

E-mail Address:

Mailing Address: Street

City

Ohio County

State

Zip

Phone

Child's date of birth (mm/dd/yyyy)

Child's date of diagnosis (month/year)

Child's Race

Child's Social Security Number (optional):

My child has insurance coverage.

My child's Eye Doctor is:

Doctor's Phone

Doctor's Address

Type of Doctor

Important: Is your child undergoing patching therapy?

(i.e., Child wears an eye patch over his/her good eye?)

If your child is undergoing patching therapy and wears glasses, has your eye doctor approved the use of cloth patches? Yes No. If Yes, which eye is being patched? Right eye Left eye

Check all the apply:

I would like to receive written brochures about amblyopia, eye safety, strabismus, etc. (Ohio residents only)

I would like to receive the following (Ohio residents only):

Letter reminders of the importance of maintaining my child's eye doctor appointments as well as newsletters and other written information about amblyopia as it becomes available.

Email reminders (be sure to include your e-mail address above) of the importance of maintaining my child's eye doctor appointments and other internet related information about amblyopia as it becomes available.

1. How was your child�s amblyopia discovered?
By eye doctor on regular exam.
Pediatrician/family doctor suggested an eye exam, which lead to the diagnosis of amblyopia.
Child failed an eye screening test (at school, daycare, etc.,) and it was recommended that child see an eye doctor who diagnosed the amblyopia.
Nurse, teacher, other non-doctor professional suggested that I take my child in for an eye exam and amblyopia was diagnosed.
Other: please explain how the child was found to have amblyopia:

2. How did you find-out about the Ohio Amblyope Registry?

From my Eye Doctor or Eye Doctor's office.

From searching the Internet.

Other; please list:

3. How can the Ohio Amblyope Registry help you, as a parent of a child with amblyopia? Please list and help us improve:

If financial assistance is needed, please speak with your eye care provider about any assistance that might be available. You can also contact your local Health Department about filling-out a Combined Programs Application (includes Medicaid and BCMH) for financial assistance to cover your child's eye care needs.

Thank You

This web site is funded by The Ohio Department of Health, Bureau of Child and Family Health Services, Save Our Sight Program.