VISION REFERRAL

Please add student name, your name, and check off any of the observations you have seen below.  Record any other comments or concerns in the "comment" box.  When finished, hit "submit" and it will be emailed directly to the nurse.  If you do not hear from the Nurse in 1 week, please follow up :)  thanks!

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* Student Name and Grade

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* Teacher Comments:

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* Name of Staff Member/Teacher Referring

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* Observations of the student:

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* Complaints of the student:

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* Check which of the following you have observed:

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