Salem Hospital Intraocular Lens Request
FAX TRANSMITTAL
503-814-2457

TO:
Intra Ocular Lens Coordinator
Day Surgery Department
Salem Hospital

FROM:
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR 97301
Date:
Time:
# of Pages:
Patient Name:
Last Name
First Name
Date of Surgery:
Lens Model
Diopter
Quantity
Product Preference
(Circle One)
Comments
Primary     Secondary
Back-Up
Primary     Secondary
Back-Up
Primary     Secondary
Back-Up

Primary     Secondary
Back-Up
Salem Hospital EMI Use Only
Request Date
Order Date
Stocked By
Notes