Salem Laser and Surgery Center, L.L.C.

LASIK PROCEDURE INFORMATION

PATIENT INFORMATION
Date:
Name:  
Sex:        
DOB:  
Age:  
Social Security #:
Referral:  
Surgeon:  
PRE-OP INFORMATION / TREATMENT PLAN
Surgery Date:
SURGERY PLANNED:     OU     OD     OS
Previous Surgery:
Monovision Near:     OD     OS
Medications:
Allergies:  
Va
OD
sc
cc
OS
sc
cc
Keratometry:
OD
OS
Corneal Topography:
OD
OS
Corn. Diam. (wtw)
OD
OS
Pachym. (central):
OD
OS
Pupil Size (dim):
OD
OS
Contact Lens History:
SCL         Torics         DW         Extended         RGP         PMMA
Mono Near:     R   L
How many years?
How long out of CL's prior to final pre-op exam?  
Target Post-Op Rx:
OD
    X  
OS
    X  
Manifest Dry:
OD
    X  
OS
    X  
Manifest Cyclo:
OD
    X  
OS
    X  
Pre-Op Optimal Rx:
OD
    X  
OS
    X  
Monovision Adjust:
OD
    X  
OS
    X  
Machine Setting
OD
OS
Vertex Dist. (mm):
OD
OS
Hansatome:
OD
8.5   9.5  /   160   180
OS
8.5   9.5  /   160   180
COMMENTS
Surgeon Signature:
Date:  
Time:  
POST-OP APPOINTMENT DATE & TIME:
LASIK PROC. INFORMATION REV. 4/04