Section B
SAMPLE
Vision Referral Letter
Date
Dear Parent/Guardian:
Recent vision screening test at school indicates that ____________________________ may have some vision
(student and grade)
difficulty. A comprehensive eye examination is recommended. Please take this form with you at the time of examination.
(School Nurse)
(School Contact information)
REASON FOR REFERRAL
Vision Test Results Screening Tool(s) used*: ___________________________
1 Blinking 1 Blurred Vision 1 Frequent headaches after reading
1 Squinting 1 Watering Eyes 1 Other ______________________________________________
Remarks
* If an automated screening was used, attach printout from the machine.
EYE EXAMINER’S REPORT TO SCHOOL
Diagnosis: ____________________________________________________________________________
← No Treatment Indicated
← Treatment Recommended
← Glasses Prescribed
← To be worn at all times
← To be worn at all times except during physical education
← To be worn for far vision activities, e.g., driving, looking at the board
← To be worn for near vision activities, e.g. computer work, reading, writing Other: _________________________________________________________________________
Vision to be expected with correction: R 20/ L 20/
Classroom/School Recommendations:
______________________________________________________________________________________
Recommended Date for Re-examination: _________________
We would appreciate any additional information which may be pertinent to this student’s school adjustment.
Date
Name of Eye Examiner (MD, DO, or OD)
Phone/Email
Signature of Eye Examiner
NOTE: Please complete and return to the school nurse. Thank you.
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