PLEASE PRINT IN LANDSCAPE!
MARCUS A. EAST, M.D.
RYAN W. LAPOUR, M.D.
JOHN G. DODD, D.O.
CHECKLIST
NAME:
SURGEON:
DATE:
TIME:
  A.M.   /   P.M.
FACILITY:
EYE:
                   
PROCEDURE:
DX:
CPT:
ANESTHESIA:
PRIOR AUTHORIZATION:
         
MEASUREMENTS:
PRE-OP APPOINTMENT:
POST-OP APPOINTMENT:
REFERRAL:
CO-MANAGE:
         
655 Medical Center Dr NE
Salem, Oregon 97301
503.581.5287