NAME:

SURGEON:

DATE:

TIME:

  A.M.   /   P.M.

FACILITY:

EYE:

OD           OS           OU

PROCEDURE:

DX:

CPT:

ANESTHESIA:

PRIOR AUTHORIZATION:

YES           NO

MEASUREMENTS:

PRE-OP APPOINTMENT:

POST-OP APPOINTMENT:

REFERRAL:

CO-MANAGE:

YES           NO