REVISED
Date:
INTRAOCULAR LENS REQUEST
Facility:
Salem Laser
/
Northbank
Patient
Age:
Surgical Eye:
Right
Left
Surgery Date:
Surgeon:
Rowell
Neahring
Stice
Warner
Gurdian
Dodd
East
Lapour
Surgery:
T Blue
Flomax
Block
LRI
LenSx
Lens
Lens Model
Diopter
Comments
PRIMARY
ALCON SN60WF
BACKUP
ALCON MA60AC
TORIC
ALCON SN6AT
MULTIFOCAL
PanOptix TFNT00
TFAT00
MULTIFOCAL TORIC
PanOptix TFNT
PanOptix TFAT
PRIMARY AMO
AMO ZCB00
A.C.
ALCON MTA4UO
LenSx
Primary
Secondary
# Arcs
Depth
Diameter
Axis
Length
Additional Lens Models
ReStor 3.0
ReStor 2.5
Symfony
Symfony Toric
SN6AD1
SN25T0
ZXR00
ZXT
11/19 | REVISED
PATIENT NAME LABEL
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