Lions of Michigan Foundation - KidSight - Eye Doctor Referred Child Report Form

Dear Eye Care Professional:

Each year, the Lions Clubs of Michigan complete vision screenings for thousands of children through Project KIDsight. Our results show that we refer eight to ten percent of the children we screen to eye care professionals for follow-up care, and about ninety percent of the children we refer require ongoing treatment for an eye disorder.

Over the years, our vision screening equipment has proven to be very accurate in identifying vision disorders in children, especially in the one to five year-old age group. However, we understand that the information provided by our mobile screening devices is not meant to be diagnostic. Thus, it is critically important that you thoroughly examine and treat the children who receive KIDsight referrals, and our hope is that, regardless of the results of your examination, you will support Project KIDsight and our efforts to ensure that no visual abnormality impedes a child’s ability to succeed in life.

We rely upon the information you provide to confirm that each of our referred children receives a complete eye examination and to ensure that our vision screening program provides accurate and reliable information.

The success of Project KIDsight is very dependent on the participation and counsel of Michigan eye care professionals. We look forward to working with you to improve the eye care of children in Michigan.

Thank you for your help.

Dr. John D. Baker, MD
Medical Director – Project KIDsight Michigan
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Referred Child:  Full Name *
Referred Child:  Date of Birth *
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Child's Referral Date
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Child's Reason for Referral
Child's Parent - Full Name *
Child's Parent - Telephone or Email
Date of Child's Eye Examination *
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Eye Doctor - Full Name *
Eye Doctor - Title *
Eye Doctor - Email
Eye Doctor - Diagnosis
Eye Doctor - Method of Testing
Child's Uncorrected Visual Acuity
Eye Doctor - Method of Assessing Alignment
Eye Doctor - Recommended Treatment *
Required
Eye Doctor - Assessment of Vision Screening Results *
Eye Doctor - Assessment of Referral *
Eye Doctor - Notes and Recommendations
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