NY - LASIK CO-MANAGEMENT FORM

LASIK REFERRAL FORM
LASIK REFERRAL FORM
COMANAGING DOCTOR INFORMATION
Co-Managing Doctor Name

First NameLast Name
Office Contact Person

First NameLast Name
Co-Managing Doctor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Co-Managing Doctor Email
example@example.com
Co-Managing Doctor Phone
Please enter a valid phone number.Format: (000) 000-0000.
Co-Managing Doctor Fax
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact
PATIENT INFORMATION
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Main Phone
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone
Please enter a valid phone number.Format: (000) 000-0000.
Day 1 Follow Up:
PRE-PROCEDURE EVALUATION

Ocular Surgical and Medical History
UCVA
OD: 20/
OS: 20/
Dominant Eye
Binocular
Pupil Size (Dim illum) OD
Pupil Size (Dim illum) OS

RX Stable x 12 mos (S 0.50 D)
Contact Lens Use
Contacts Removed (Date)

MonthDayYear
Date
FDA Recommendations: Soft lenses removed 2 weeks prior to final evaluation and/or surgery day. If extended wwear or soft toric, remove 3 weeks prior, RGP/PMMA remove for a minimum of 4 week per decade of wear. If PMMA, add two (2) weeks. Must confirm stability with refraction and topo. Center to confirm stability prior to procedure.

Anterior Segment

Posterior Segment