INTRAOCULAR LENS REQUEST
To: Northwest Medical
From:
Dr. East
Dr. Lapour
Dr. Dodd
Patient:
DOB:
Age:
Sx Date:
Nuclear
Combined
PSC
Cortical
Mature
OD
OS
ECP
Canaloplasty (ABiC)
Primary
Diopter
Back Up
Diopter
Alcon
Alcon
MA60AC
AMO
TECNIS
AMO
AR40
B&L
MX60
Toric
Multifocal
Symfony
AC-Alcon
MTA4U0
Other
OTHER
LRI
Malyugin Ring
Trypan Blue
Dexamethazone Inj
CTR
Astigmatism
Persistant Miosis
Mature Cataract
Kenalog
PXE
Comments
Verified ( Surgeon )
Date
Submitted ( Tech )
Date / Time
MCEC OFFICE USE ONLY
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