REVISED
Date:
INTRAOCULAR LENS REQUEST
Facility: Salem Laser / Northbank
Patient Name:
Date of Birth: 
Age:
Surgical Eye:
Surgery Date:
Surgeon:
Surgery:
Lens
Lens Model
Diopter
Comments
PRIMARY
BACKUP
TORIC
MULTIFOCAL
MULTIFOCAL TORIC
PRIMARY AMO
A.C.
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