Report Request Form Name First Last PhonePatient Name First Last Date MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Report needed by (date) MM slash DD slash YYYY For IEP ($59) 504 ($59) VT Progress ($43) ACT ($96) Other (varies) If school accommodations are needed please be as specific as possible regarding what you would like included in your report: (Example: Testing in a room free of distractions, etc...) CostPlease provide your method of payment below. Payment is due when your report is requested. Fax request to (405) 755-1875 or email to info@afeyecare.com. Please allow 2-3 weeks for report. Thank you Cash Check Card Visa MasterCard Amex Discover Card NumberExpiration MM slash DD slash YYYY Security Code SignatureRequest taken by