Salem Laser and Surgery Center, L.L.C.
LASIK PROCEDURE INFORMATION
PATIENT INFORMATION
PRE-OP INFORMATION / TREATMENT PLAN
Surgery Date:
SURGERY PLANNED:
OU
OD
OS
Previous Surgery:
Monovision Near:
OD
OS
Va
OD
sc
cc
OS
sc
cc
Contact Lens History:
SCL
Torics
DW
Extended
RGP
PMMA
Mono Near:
R
L
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
Hansatome:
OD
8.5
9.5 /
160
180
OS
8.5
9.5 /
160
180
LASIK PROC. INFORMATION REV. 4/04