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School Nurse Referrals

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Please contact us with the following information:

  • Date
  • Patient Name
  • Referring School
  • School Nurse
  • Fax

Suspected problem or symptoms (free for infants 6-12 months and for students 5-15 years):

  • Infant Examination Checklist
  • Poor distance Vision
  • Poor near vision
  • Eye strain or fatigue
  • Headaches
  • Pain in or around eyes
  • Eye turn
  • Family history of eye turn
  • Poor school performance
  • Computer vision problems

Other Issues:

  • Pink Eye
  • Flashers or Floaters
  • Something in eye
  • Other condition or concerns (please describe)