Transcription of Refractive Surgery Referral - odpcli.com
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Refractive Surgery Referral - odpcli.com
REFERRING DOCTORName Address Phone ( ) Date of examRefractive Surgery ReferralPATIENT INFORMATIONName Address Date of birthPhone: Hm ( ) Wk ( )Check if normal: OD OS OD OS Adnexa Lens Anterior segment abnormal findings Lids/lashes Vitreous Conjunctiva Disc Cornea Vessels Posterior segment abnormal findings AC Macula Iris Periphery mm APD + / - (circle)20 / 20 / 20 / 20 / @ @mm HgmicronsOD mm APD + / - (circle)20 / 20 / 20 / 20 / @ @mm HgmicronsOSSUBJECTIVEO cular h
REFERRING DOCTOR Name Address Phone ( ) Date of exam Refractive Surgery Referral PATIENT INFORMATION Name Address Date of birth Phone: Hm ( ) Wk ( )
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