1330 Commerical St. SE
Salem, OR 97302-4206
Lens Order Sheet
Patient & Procedure
Right
Eye
Left
Eye
Patient Name:
Date of Birth:
Age:
Date of Surgery:
Surgeon:
Dodd
East
Gurdian
Lapour
Neahring
Rowell
Stice
Warner
Surgery:
Cataract Removal with IOL
iStent
LenSx
Retrobulbar BLOCK
Comment:
Pull/Bundle
Just Prior
Lens
Lens Model
Diopter
ORDER CONFIRMATION
-For Center Use Only-
STANDARD
ALCON, SN60WF
AMO, ZCB00
Ordered by: Date:
Conf No:
Ship:
2nd Day
Overnite
TORIC
ALCON IQ Toric
,
SN6AT
Ordered by: Date:
Conf No:
Ship:
2nd Day
Overnite
REFRACTIVE
ALCON ReSTOR
,
SN
AMO SYMFONY
, ZXR00U
Ordered by: Date:
Conf No:
Ship:
2nd Day
Overnite
REFRACTIVE TORIC
ALCON ReSTOR Toric
,
S
AMO SYMFONY Toric
,
ZXT
Ordered by: Date:
Conf No:
Ship:
2nd Day
Overnite
BACKUP
ALCON MA60AC
Ordered by: Date:
Conf No:
Ship:
2nd Day
Overnite
ANTERIOR
CHAMBER
ALCON MTA4UO
Ordered by: Date:
Conf No:
Ship:
2nd Day
Overnite
SPECIAL
ORDER
ALCON
:
AMO
:
OTHER
:
Ordered by: Date:
Conf No:
Ship:
2nd Day
Overnite
LenSx Programming
Lens:
Preset
None
Capsule:
Preset
None
Primary:
Preset
None
Secondary:
Preset
None
Arcuate:
Number of Arcs:
None
1 Arc
2 Arc
% Posterior Depth:
Arc Diameter [mm]:
Arc 1:
Position:
[degrees]:
Angle
[degrees]:
Arc 2:
Position:
[degrees]:
Angle
[degrees]:
IOL & LenSx Order Sheet 112017 Revised 11/08/2017
PATIENT LABEL
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