NY - LASIK CO-MANAGEMENT FORM

NY - LASIK CO-MANAGEMENT FORM

LASIK REFERRAL 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.
Co-Managing Doctor Fax
Please enter a valid phone number.
Preferred Contact*

PhoneFaxMailEmail
PATIENT INFORMATION
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemale
Main Phone*
Please enter a valid phone number.
Additional Phone
Please enter a valid phone number.
Day 1 Follow Up:*

Co-Managing DoctorSightMD
PRE-PROCEDURE EVALUATION

Ocular Surgical and Medical History
UCVA*
OD: 20/*
OS: 20/*
Dominant Eye*

ODOS
Binocular*

NLAbnormal
Pupil Size (Dim illum) OD*
Pupil Size (Dim illum) OS*

Rows	OD	OS	Date
Current RX
Dry
CYCLO
K's

RX Stable x 12 mos (S 0.50 D)*

YesNo
Contact Lens Use*

D.W.SCLX.W.SCLToric SCLRGPPMMA
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*

Rows	Lids/Conjunctive	Cornea	Lens	IOP (mmHg)	Pachymetry (Microns)
OD
OS

Posterior Segment*

Rows	Dilated	C/D Ratio0.	Myopic Degeneration	Retina
OD
OS

Recommended*

PRKLASIKPTKICLOther
ODOSBilateral
Aim Distance OUAim Near ODAim Near OS
Mono Target*
Patient Shown Mono with*

Contact LensesTrial Frame
Discussed

Benefits & RisksPresbyopia / MonovisionEnhancement
Scheduled at SightMD*

SurgeryConsult / Additional TestingEnhancement
Scheduled at SightMD Date

MonthDayYear
Date
Comments
SightMD Surgeon:*
Referring Doctor Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: