Infant & Children’s Vision Resources supported by
The American Optometric Association and
Optometry Cares – The AOA Foundation
SAMPLE LETTER [NOT A TEMPLATE]
REFERRAL TO OCCUPATIONAL THERAPIST
[Date]
Re: [Patient Name] DOB: [Date of Birth]
Dear [Optometric Therapist]:
I had the pleasure of evaluating [Patient Name] on [Date of Appointment] pursuant to your referral. You noted in
your assessment that [Patient Name] was having trouble following you with his eyes, and with concentrating both
eyes on one object.
My examination revealed that [Patient Name] has normal ocular motility (or eye tracking) and binocular vision (or
eye teaming). With visual stimuli of interest, he/she was able to converge normally, to cross the midline effectively
and has no restriction in the range of his eye movements in any quadrant. [Patient Name] does however have
significant latent hyperopia or farsightedness in both eyes, revealed under the influence of 1% cyclopentolate eye
drops. These drops relax the focusing mechanism of the eye which can be very labile in some children. The
extra effort that [Patient Name] expends on attaining and maintaining focusing accuracy at near objects may
account for your observations. I therefore prescribed a low power prescription to aid his focusing for learning
activities, which should also be of benefit while you are undertaking therapy with him/her.
I have advised [Patient Name]’s mother to return with him/her in two months to see how he/she is responding to
the prescription, particularly with regard to your original observations and concerns. Thank you for the opportunity
to be of assistance in [Patient Name]’s visual care. If you have any questions, please do not hesitate to call.
Sincerely,
[Doctor Signature Information]
