Salem Hospital Intraocular Lens Request
FAX TRANSMITTAL
503-814-2457
Intra Ocular Lens Coordinator
Day Surgery Department
Salem Hospital
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR 97301
Lens Model
Diopter
Quantity
Product Preference
(Circle One)
Comments
Primary
Secondary
Back-Up
Primary
Secondary
Back-Up
Primary
Secondary
Back-Up
Salem Hospital EMI Use Only