VISION REFERRAL FORM

Date: _________

Dear Parent/Guardian,

_______________________________(along with other students in our school) has been given a vision screening test. The results indicate that a further evaluation is needed. Please take the enclosed results to your eye doctor.

Screening results: Right ______ Left _______

With ______ Without Lenses

Please return the doctor’s statement after your child has been evaluated by the eye doctor.

_________________________________

School Nurse/School Nurse Practitioner

Result of eye exam: ______________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Date: ____________ Doctor’s Signature: __________________________

Please check one of the following and return to the school nurse.

( ) I will consult my family eye doctor as soon as possible.

( ) I have made an appointment on ________ with Dr. _________________________

( ) I have requested financial assistance for eye care.

___________________________ _______________________________

Student’s Name and Grade Signature of Parent/Guardian