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VISION REFERRAL AND REPORT FORM Tagalog
VISION REFERRAL AND REPORT FORM Tagalog
Mahal na Magulang,
( ) Opo, ang anak ko ay papasuri ko sa aming pribadong doctor sa mata at isasauli namin ang form na ito
( ) Opo, ipapaubaya namin na makita ang anak namin ng doctor sa mata mula sa pamahalaang local
( ) Hindi po namin, pinapayagang masuri ang anak namin ng doctor sa mata. Naiintindihan naming ang pag ayaw
namin ay maaring mag hantong sa pagkalabo ng mata ng anak naming
________________________________ _____________________________
Pangalan at Lagda ng Magulang Panagalan at Lagda ng Screener
Petsa ____/____/____ Petsa ____/____/____
Visual Acuity:
Without Lenses With Lenses
Right Eye: ___________________________ ________________________
Left Eye: ___________________________ ________________________
Recommendation(s):
Glasses needed: ( ) Yes ( ) No.
If YES, the prescription has been given to __________________________________
Return visit: ( ) 1 Year ( ) _______________________________________________
_____________________________________
Name and Signature of Eyecare Professional