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  • ISEE Referral Form Final

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    Tori Lee
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    This referral report provides information about a patient's eye examination. It includes the patient's name, date of birth, address, health care number, school, and date of examination. The optometrist identifies whether the patient has refractive issues like myopia, hyperopia, or astigmatism that require correction. They also note any binocular vision issues like strabismus or non-strabismic problems. Finally, the optometrist indicates if the patient has any ocular health issues and outlines the management plan for any refractive or binocular vision problems.

    Original Description:

    Vision Screening Form

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    This referral report provides information about a patient's eye examination. It includes the patient's name, date of birth, address, health care number, school, and date of examination. The optometrist identifies whether the patient has refractive issues like myopia, hyperopia, or astigmatism that require correction. They also note any binocular vision issues like strabismus or non-strabismic problems. Finally, the optometrist indicates if the patient has any ocular health issues and outlines the management plan for any refractive or binocular vision problems.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    16 views1 page

    ISEE Referral Form Final

    Uploaded by

    Tori Lee
    This referral report provides information about a patient's eye examination. It includes the patient's name, date of birth, address, health care number, school, and date of examination. The optometrist identifies whether the patient has refractive issues like myopia, hyperopia, or astigmatism that require correction. They also note any binocular vision issues like strabismus or non-strabismic problems. Finally, the optometrist indicates if the patient has any ocular health issues and outlines the management plan for any refractive or binocular vision problems.

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    CONFIDENTIAL

    Please fax or email this information back to:


    Alberta Association of Optometrists
    #100, 8407 Argyll Rd NW
    Edmonton, AB T6C 4B2
    ATTENTION: ISEE

    Referral Report
    FAX: 780-452-9918
    Email: ISEE@optometrists.ab.ca

    Patient Name F i r s t n a m e , L a s t n a m e q Male q Female

    Date of birth D a y / M o n t h / Y e a r

    Address

    City / Province

    Postal Code

    Alberta Health Care Number

    School Name

    Date of Eye Examination D a y / M o n t h / Y e a r

    Name of Optometrist

    Clinic Name

    If the child has refractive issues, the child has If the child has binocular vision issues, the child has
    (check all that apply): (check all that apply):
    ❏❏ Myopia that requires an Rx ❏❏ Constant strabismus
    ❏❏ Hyperopia that requires an Rx ❏❏ Intermittent strabismus
    ❏❏ Astigmatism that requires an Rx ❏❏ Strabismic Amblyopia
    ❏❏ Refractive amblyopia ❏❏ Non strabismic binocular vision problems:
    ❏❏ Refractive error that does not require an Rx at this time ❏❏ Convergence insufficiency
    ❏❏ Other (please specify) _________________________ ❏❏ Convergence excess
    ❏❏ Accommodative insufficiency
    The management plan for this child’s refractive issue(s) is: ❏❏ Accommodative excess
    (check all that apply): ❏❏ Accommodative infacility
    ❏❏ Monitor ❏❏ Other (please specify): ________________________
    ❏❏ Prescribe glasses ____________________________________________
    ❏❏ Patching/ atropine/ penalization
    ❏❏ Other:_______________________________________ The management plan for this child’s binocular vision issue is:
    ❏❏ No intervention; monitor
    If the child has ocular health issues, the child has ❏❏ Refer to ophthalmology
    (check all that apply): ❏❏ Refer to BV clinic for vision therapy
    ❏❏ Visually significant cataract ❏❏ In office vision therapy
    ❏❏ Red eyes (please specify your findings) ❏❏ Pencil push ups
    ____________________________________________ ❏❏ Prescribed glasses
    ❏❏ Other: ______________________________________
    ❏❏ Itchy eyes (please specify your findings)
    ____________________________________________
    ❏❏ Swollen eyelids (please specify your findings) Confidentiality Notice: This fax contains confidential and/or
    privileged information and is intended only for the ISEE program
    ____________________________________________ at fax number 780-452-9918. Any disclosure, copying, distribu-
    ❏❏ Dry Eyes tion, or reliance upon the contents of this fax not otherwise au-
    thorized by the ISEE program is strictly prohibited. If you have
    ❏❏ Other (please specify your findings) received this fax transmission in error, please immediately con-
    tact the Clinic Name noted on the report, so that proper delivery
    ____________________________________________ of the fax can be effected, and then please destroy the fax.

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