Referral For An Eye Examination Form printable pdf download

Referral for an Eye Examination

January 24, 2014

Dear Parent/Guardian:

We routinely screen vision to identify children who have vision problems or might be at risk for vision problems. We

refer children for an eye exam when they do not pass vision screening or are at risk of a vision problem because of a

medical or developmental reason. Vision screening does not replace a complete eye exam, but it might suggest a

referral to an eye doctor for a comprehensive eye exam.

You are receiving this document because your child __First, M.I., Last____________________________ had his/her

vision screened or should have an eye exam because of a medical or developmental risk for a vision problem and

needs a complete eye exam with an eye doctor (an optometrist or an ophthalmologist.) It is important to schedule

this exam as soon as you can. Do not miss this appointment. If the eye doctor finds a vision problem, early treatment

leads to the best possible results for your child’s vision. The back of this form lists the reason(s) for this referral.

The back of this page lists the reason(s) for this referral.

Please:

Complete the Consent and Release of Information block below AND the top part of the back of this page.

Take this paper with you to the eye exam and give the form to your eye doctor.

Ask the eye doctor to send exam results to us and discuss the eye exam results with us, if necessary.

If you need help finding a local eye doctor for your child’s appointment, use the website links below. Many programs

help cover all or part of eye care expenses for children. Let us know if you want information about these programs.

Sincerely,

[Referring primary care provider, school nurse, Head Start staff, Other, ]

[Practice/Office/School/Agency name and address

]

Consent and Release of Information

By my signature below, I authorize: (1) the vision screening agency to release my child’s vision screening results and/or

medical or developmental reason for an eye exam to the eye doctor and medical doctor (if screening did not occur in the

medical home), (2) my child’s eye doctor to send exam results to the vision screening agency, (3) the vision screening

agency and eye doctor to discuss eye exam results, (4) and the vision screening agency to send exam results to the

child’s medical doctor (if screening did not occur at the medical office) for the specific purpose of notifying my child’s

healthcare and educational providers of any specific vision problems, recommendations, and treatment instructions

related to my child’s vision needs. I understand that I may refuse to sign this authorization and that my refusal will not

affect my ability to obtain an eye exam for my child or assistance with payment for the eye exam.

________________________________________________________________ ________________________________

(Signature of parent/guardian)

(Date)

Find an eye doctor near you:

 American Academy of Ophthalmology:

 American Optometric Association:

 Centers for Medicare and Medicaid

Services:

 American Association for Pediatric Ophthalmology and Strabismus:

 All About Vision:

 College of Optometrists in Vision Development:

Referral For An Eye Examination Form