Form M-144 - Vision Screening Referral Form - School Health Services The School District Of Philadelphia Page 2

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EYE CARE SPECIALIST REPORT
FAR
NEAR
PRINT NAME OF EYE CARE SPECIALIST
PLEASE RETURN THIS FORM TO SCHOOL - ATTENTION: SCHOOL NURSE
SCHOOL NAME:_____________________________________________
SIGNATURE
ADDRESS: _________________________________________________
TELEPHONE
ZIP CODE: _____________________
OR FAX TO:_________________________________________________
M-144 (Rev. 8/03) Comm. Code 61602445259

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