Salem Laser and Surgery Center
LASIK Flow Sheet / Orders
PRE-OPERATIVE HISTORY
Chief Complaint: reduced vision due to near-sightedness / far-sightedness / astigmatism
Other:
Pre-op Diagnosis: Myopia / Hyperopia /
Astigmatism OD OS
OU
Other:
Planned Procedure: LASIK / Enhancement /
PRK / PTK OD OS
OU
Other:
Significant Medical History:
Current Medications and Dosages:
Drug Allergies:
RXN:
NAUSEA
VOMIT
RASH
SHOCK
OTHER
REASSESSMENT: H & P Current and valid. No Changes
Procedure: LASIK / Enhancement /
PRK / PTK OD OS
OU
Anesthesia: Alcaine 0.5% gtt in oper. Eye(s)
RN Signature
Date
Physician Signature
Date
Time
LASIK FLOW SHEET REV 07/18
PATIENT LABEL