Service User Name LL Number Does this person have any visual difficulties? YesNo Comments Is this person registered blind/partially sighted? YesNo Comments Does this person wear glasses? YesNo Comments Does this person use aids? (i.e. magnifying glass, talking book, Braille) YesNo Comments Eye Care required? (e.g. use of creams) YesNo Comments Supervisor Notes D&J Care Services undertakes that it will treat any personal information (that is data from which you can be identified, such as your name, address, e-mail address etc) that you provide to us, or that we obtain from you, in accordance with the requirements of the Data Protection Act 1998 Supervisor Supervisor Signature Date
