Request For Hearing and/or Vision Screening Results

The Allegan County Health Department frequently receives requests for screening results for preschool, kindergarten entrance, driver's training and more. Please complete the form below to request a copy of your child's screening results. A copy of these results will be securely mailed to a parent/guardian. Certificates will be mailed within 5 business days after the Hearing and Vision program team receives a request.

1. Please list your information:

Parent/Guardian First Name
Parent/Guardian Last Name
Address (City, State, ZIP)
Phone Number
Email

2. Please list child's information:

First Name
Last Name
Date of Birth (MM/DD/YYYY)
Name of School Child Attends
Child's Grade at the Time of Screening

3. What screening results are you requesting?

Please enter an 'other' value for this selection. * This question is required.