vision referral to be completed by physician

vision referral to be completed by physician

Mission Consolidated Independent School District
Health Services VISION REFERRAL ID# Grade Dear Parent of RE: FINAL NOTICE regarding a FAILED Vision Screening On________________you were notified that your child failed their Vision Screening. As of today we have not received the required vision report from the eye doctor. Undiagnosed and untreated eye and vision problems can interfere with learning and contributes to poor performance in school. Please contact the school nurse immediately and let her know what the barrier is to obtaining a professional eye exam for your child or if you need financial assistance. Your attention in this matter is needed as Mission CISD is required to report all incomplete referrals to the State of Texas. To help your child, we will continue with classroom accommodations pending evaluation. Please follow this checklist: 1. Schedule an eye appointment with an optometrist or ophthalmologist immediately. 2. Take this letter/vision report to the eye appointment. 3. Have the eye doctor complete the report below. 4. Results from the eye doctor MUST be brought to your campus nurse within 10 days of the date of this letter. 5. If glasses are needed, ask about getting warranty to cover lost or broken glasses. For your convenience, attached is a list of some local eye doctors. Acuity: Reason for referral: Symptoms: Hirshberg C.L.R.T. Cover/Uncover: Ph# Date: School Nurse: TO BE COMPLETED BY PHYSICIAN 1. Chief Complaint: 2. Observation: A. Vision unaided 20/ OD 20/ OS B. Vision aided 20/ OD 20/ OS C. Muscle: D. Color Vision: 3. Impressions: 4. Recommendations: Doctor (print) Doctor’s Signature/Date Ph#: Address: City: State: Zip: Mission Consolidated Independent School District
Health Services REFERENCIA PARA EXAMEN DE LA VISTA ID# Grado Estimados Padres de RE: NOTA FINAL Tocante Examen de la Vista usted fue notificado que su hijo(a) fallo su examen de la vista. Hasta ahora no hemos En recibido el reporte requerido del oculista. Problemas de la vista no diagnosticadas pueden interferir con el aprendizaje y contribuye con el desempeño deficiente en la escuela. Por favor de ponerse en contacto con la enfermera de escuela inmediatamente y déjela saber cuál es la barrera en obtener un examen profesional de la vista para su hijo(a) o si hay una necesidad financiera. Su atención en este asunto es necesaria ya que el distrito escolar de Mission es requerido a reportar todas las referencias incompletas al estado de Texas. Ya que la buena vista es esencial para el éxito escolar de su hijo(a), se harán acomodaciones en la clase mientras el tratamiento este pendiente. Por favor siga esta lista: 1. Hacer una cita con un optometrista u oftalmólogo inmediatamente. 2. Lleve esta carta/informe de vista a la cita. 3. El oculista necesitara que completar el informe abajo. 4. Los resultados del médico DEBEN ser entregados a la enfermera de escuela dentro de 10 días de la fecha de esta carta. 5. Si anteojos son necesarias, pida información tocante garantía que cubra lentes quebrados o perdidos. Para su conveniencia, atada esta una lista de algunos optometristas/oftalmólogos locales. Razón para referencia: Acuity: Symptoms: Hirshberg C.L.R.T. Cover/Uncover: Tel# Fecha: Enfermera de Escuela: TO BE COMPLETED BY PHYSICIAN 1. Chief Complaint: 2. Observation: A. Vision unaided 20/ OD 20/ OS B. Vision aided 20/ OD 20/ OS C. Muscle: D. Color Vision: 3. Impressions: 4. Recommendations: Doctor (print) Doctor’s Signature/Date Ph#: Address: City: State: Zip: