Vision Referral Letter - Action and Form Instructions

Sep 15, 2026

Uploaded by Blaney

Vision referral letter template for parents/caregivers following school vision screening. Includes child identification fields, date of birth, screening date, and recorded results for right and left eye distance vision, with notes on inability to read chart lines, differences between eyes, near-vision difficulty, complaints about seeing clearly, atypical eye appearance, and possible muscle or retinal red-light reflex findings. Provides instructions to take the child to an eye doctor, includes sections for provider examination findings, treatment recommendations, follow-up timing, and school nurse return details, referencing Minnesota Department of Health guidelines.

LanguageEnglish

CategoryLetters

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Vision Referral Letter

Parent/Caregiver Instructions

Screening Results and Referral Reason

Health Care Provider Section

School Nurse/Health Staff Return Section

Vision Referral Letter Child’s Name: Date of Birth: Dear Parent/Caregiver: Our school provides vision screening using the guidelines developed Minnesota Department of Health. Your child’s vision was screened on Please take your child to an eye doctor to check their vision. Give this letter with the school vision screen results to the eye doctor. 􀀀 Right Eye 10/ (20/ ) Left Eye 10/ (20/ ) for distant vision. 􀀀 Your child was unable to read lines on the chart for their age OR the difference between vision in the left and right eye was greater than one line (with) (without) corrective lenses. 􀀀 Your child had trouble seeing objects close-up (Plus lens screening) . 􀀀 Your child complained that it is hard to see well. 􀀀 The appearance of your child’s eye/s was not typical for most children. Explanation: _________________________________________________________ 􀀀 Possible eye muscle balance problems (pupils looking the same direction) was observed during screening 􀀀 Abnormal Retinal (Red Light) Reflex 􀀀 Child/Family history of eye conditions. If you have questions or need help getting an exam by an eye care professional, please contact us. Please have your eye care professional complete the form and return the completed form to your school. Health Care Provider, please complete this form. Child’s Name: Date of Birth: School Name: Provider comments: I have examined this child on / / My findings are: Right: 10/ (20/ ) Left: 10/ (20/ ) without corrective lenses 􀀀 Insufficient to require treatment 􀀀 Corrective lenses prescribed or there is change in the current prescription. 􀀀 Best Correction: R / L / 􀀀 Muscular Condition was not found or insufficient to require treatment 􀀀 Muscular Condition is being treated by corrective lenses or other method 􀀀 There is no significant visual condition that will impact the child’s learning 􀀀 This child has a visual condition that may impact learning. Recommendations include: 􀀀 􀀀 Other Child should return for follow up examination on Provider Name/Title: Contact Information: Schools nurse or health staff fill out this section below before sending home Please have the parent return this form to the school or you can return this to School Nurse Name: Phone: Address: __________________________________________________________________________ Email: This templated form was developed by MDH for use in schools. Minnesota Department of Health Child and Teen Checkups 651-201-3650 [health.childteencheckups@state. mn.us](health.childteencheckups@state. mn.us) [www.health.state. mn.us](www.health.state. mn.us) 11/2023 To obtain this templated in a different format, call: 651-201-3650.

FAQs

What information does the vision referral letter ask parents to complete for their child?

It includes the child’s name and date of birth, the screening date, and the school name. It also uses the provided screening results to explain why a referral is recommended.

When should parents take the child to an eye doctor?

Parents should take the child to an eye doctor to check their vision after receiving the school’s vision screen results. The letter asks the parent to give the completed results to the eye doctor.

What should the eye care provider complete in the form?

The provider is asked to record examination date, right and left eye measurements without corrective lenses, assessment of whether treatment is needed, recommended best correction, and any recommendations that may impact learning, plus follow-up timing and provider contact details.

Sep 15, 2026

Uploaded by Blaney