MARCUS A. EAST, M.D.
RYAN W. LAPOUR, M.D.
JOHN G. DODD, D.O.
CO-MANAGEMENT SERVICES
TYPE OF CONSULTATION
LASIK Evaluation
Cataract Evaluation
YAG Laser Capsulotomy Evaluation
Other
Attn:
SURGERY COORDINATOR
Please fax form to :
(503) 386-1377
Date
REFERRING PROVIDER INFORMATION
Referral Submitted by
Clinic Name
Ordering Provider
PATIENT INFORMATION
MALE
FEMALE
Name
DOB
Referring Doctor
Date of Exam
CLINICAL INFORMATION
( Please provide any information available )
Manifest Refraction
OD
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
Balance
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
SPH
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
×
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
OS
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
Balance
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
SPH
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
×
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
Add
+.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
Old Rx
OD
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
Balance
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
SPH
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
×
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
OS
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
Balance
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
-20.00
-19.75
-19.50
-19.25
-19.00
-18.75
-18.50
-18.25
-18.00
-17.75
-17.50
-17.25
-17.00
-16.75
-16.50
-16.25
-16.00
-15.75
-15.50
-15.25
-15.00
-14.75
-14.50
-14.25
-14.00
-13.75
-13.50
-13.25
-13.00
-12.75
-12.50
-12.25
-12.00
-11.75
-11.50
-11.25
-11.00
-10.75
-10.50
-10.25
-10.00
-9.75
-9.50
-9.25
-9.00
-8.75
-8.50
-8.25
-8.00
-7.75
-7.50
-7.25
-7.00
-6.75
-6.50
-6.25
-6.00
-5.75
-5.50
-5.25
-5.00
-4.75
-4.50
-4.25
-4.00
-3.75
-3.50
-3.25
-3.00
-2.75
-2.50
-2.25
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
Balance
SPH
0.00
+0.25
+0.50
+0.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
+6.25
+6.50
+6.75
+7.00
+7.25
+7.50
+7.75
+8.00
+8.25
+8.50
+8.75
+9.00
+9.25
+9.50
+9.75
+10.00
+10.25
+10.50
+10.75
+11.00
+11.25
+11.50
+11.75
+12.00
×
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Add
+.75
+1.00
+1.25
+1.50
+1.75
+2.00
+2.25
+2.50
+2.75
+3.00
+3.25
+3.50
+3.75
+4.00
+4.25
+4.50
+4.75
+5.00
+5.25
+5.50
+5.75
+6.00
Keratometry
OD
-
×
OS
-
×
Pachymetry
OD
OS
Tonometry
OD
OS
Past Ocular Hx:
Current Medications:
Ocular Medications:
Drug Allergies:
Medical Hx:
Additional Info or Requests:
FOR CATARACTS PLEASE INDICATE ANY IOL PREFERENCE/INTEREST
Standard
Multifocal
Toric
Accommodating
Monovision
655 Medical Center Dr NE
|
Salem, Oregon 97301
|
503.581.5287
|
Fax 503.386.1377
|
mceyeclinic.com
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