Please Return Completed Form to School Nurse/Health Office

Referral Date______

Dear Parent/Guardian:

The results of the vision screening completed at school indicate that your child would benefit from a professional vision exam.

Please take this letter and the attached Vision Screening & Referral Form to an eye specialist. This information will provide the eye care specialist with important information. The specialist should complete the bottom of the form. After the eye specialist exam, please return the completed form to the school nurse.

Please note: □ Your child was NOT wearing glasses for this screening. □ Your child reported his/her glasses are lost or broken. □ We were unable to screen your child. If you have any recent vision screening results, please provide a copy to the school health office. □ This is the second referral letter you have been sent on these results. □ Other______

If your child is currently under the care of an eye care specialist, please let your school nurse know by completing the box below and returning this form to the school health office.

If you have any questions concerning this referral, please do not hesitate to contact the school nurse, ______, at______.

If finances are a concern and you do NOT have insurance, please call the school nurse. Financial assistance may be available through various agencies.

Thank you,

School Nurse Date:______Revised 8/2013 NM School Vision Screening & Referral Form

School Screening Report

1st Date Screened ____/______/______(mm) (dd) (yyyy) □ With correction □ Without correction 2nd Date Screened ____/______/______(mm) (dd) (yyyy) □ With correction □ Without correction □ Screened via photoscanner

□ Pass

□ Fail

Date ___/_____/______(mm) (dd) (yyyy)

Distance Visual Acuity: R 20/______L 20/_____

Distance Visual Acuity: R 20/______L 20/______

Ocular Alignment (Random Dot E/Stereotest) □ Pass □ Fail □ Did Not Test Color Vision

□ Pass □ Fail □ Did Not Test Clinical Observation Notes

Dear Eye Care Specialist: Please see the vision screening results for the above named student. Please complete the Eye Care Specialist Report and fax the completed form to the school nurse listed above.

Eye Care Specialist Report Revised 8/2013 Date of Exam:

______/______/_____ (yyyy) (mm) (dd) Overall Findings: □ Normal exam, no glasses needed □ Significant refractive error, glasses needed □ Strabismus □ Amblyopia □ Other (please specify):______

Distance Visual Acuity:

Without Correction R______L______

With Current Prescription R______L______

With New Prescription R______L______

Cycloplegia is necessary for accurate refraction in children. Agent used: □ Cyclopentolate □ Tropicamide □ None

Was a prescription for glasses given? □ Yes □ No

Cycloplegic Refraction Vision Glasses Prescription Given Sphere Cylinder Axis Sphere Cylinder Axis OD OS

Do you need to see this child again? ______When?______

Recommendations (other than glasses): □ Patching □ Atropine drops □ Referral to pediatric eye specialist □ Other (specify):______

Eye Specialist: ______Office Phone Number: _(_____)______Office Fax Number: ______Office Address: ______

Revised 8/2013