Laser Vision Correction Treatment Plan Patient and Scheduling Information Name:
Phone Number:
Date of Birth:
Age:
Gender: Male / Female
Procedure Type:
Procedure Date:
Eye: OD OS OU
Surgeon:
Mono: OD OS
Comanage Dr.
Ring Size 8.5 9.5 Mitomycin
Plate 160 180
Temp
Y / N
Humidity
Pach
IntraLase Y / N
Pre-op Data OD In Minus Cyl ONLY Refraction Manifest Cyloplegic WAMR
Sphere
Cylinder
Axis
BCVA
Cylinder
Axis
BCVA
Keratometry (flat/steep) Intended Treatment Pre-op Data OS In Minus Cyl ONLY Refraction Manifest Cyloplegic WAMR
Sphere
Keratometry (flat/steep) Intended Treatment
OD
OS