POST PROCEDURE CARE - LASIK
SightMD POST PROCEDURE LASIK
SightMD POST PROCEDURE LASIK
Patient Name
First Name
Last Name
Co-Managing Doctor
First Name
Last Name
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.
SightMD Surgeon
*
Please Select
Aaron Avni, MD - East Patchogue
Aaron Avni, MD - Port Jefferson Station
Sima Doshi-Carnevale, MD - Manhasset
Sima Doshi-Carnevale, MD - Garden City
Jonathan Ellant, MD - NYC 114 27th St
Jonathan Ellant, MD - NYC Park Ave
Jonathan Ellant, MD - Brooklyn
Jordan Garelick, MD - Bethpage
Alexander Hatsis, MD - Rockville Centre
Alex J. Hatsis, MD - Rockville Centre
Alex J. Hatsis, MD - Manhasset
David Immanuel, MD - Garden City
Brad Kligman, MD - Manhasset
Faye Knoll, MD - Deer Park
Faye Knoll, MD - Holbrook
Jeffrey Martin, MD - Smithtown
John Mauro, DO - Smithtown
John Passarelli, MD - Brentwood
John Passarelli, MD - Hauppauge
John Passarelli, MD - Sayville
John Passarelli, MD - West Islip
Eric Rosenberg, DO - Babylon
Eric Rosenberg, DO - Plainview
Surajit Saha, MD - Brentwood
Surajit Saha, MD - Hauppauge
Surajit Saha, MD - Huntington
Surajit Saha, MD - West Islip
Daniel Sambursky, MD - Johnson City
*
Procedure Date
Procedure Type
Original RX
Original BCVA: 20/
Age
Aim
Right Eye
Primary LASIK
Enhancement
Plano
Mono
Original RX
Primary LASIK
Enhancement
Plano
Mono
Exam Information
*
Exam Date
Post Op Type
Right Eye
Day 1
Week 1
Week 2
Week 3
Month 1
Month 2
Month 3
Month 6
Month 9
Month 12
Left Eye
Day 1
Week 1
Week 2
Week 3
Month 1
Month 2
Month 3
Month 6
Month 9
Month 12
*
PT Remarks
Right Eye
Left Eye
Meds
*
Meds
Meds (Cont)
Right Eye
Q 1hr
QID
TID
BID
QD
NiL
Q 1hr
QID
TID
BID
QD
NiL
Left Eye
Q 1hr
QID
TID
BID
QD
NiL
Q 1hr
QID
TID
BID
QD
NiL
UCVA
*
20/
Fluctuating Vision
Right Eye
Blurry
Glare
Double
Fluctuates
Left Eye
Blurry
Glare
Double
Fluctuates
Refraction
*
Auto Refraction
(Wet / Dry )
20/
Right Eye
Wet
Dry
Left Eye
Wet
Dry
LASIK Corneal Flap
*
Position
Clarity
Interface
Edges
Right Eye
Excellent
Dislodged
Striae
Clear
Edema
Haze
Clear
Opacities
Epi. ingrowth
Smooth
Rolled
Eroded
Left Eye
Excellent
Dislodged
Striae
Clear
Edema
Haze
Clear
Opacities
Epi. ingrowth
Smooth
Rolled
Eroded
IOP ( after 1 week/applanation):
*
mmHg
Right Eye
Left Eye
*
Doctor Comments
Enhancement
Follow Up
Right Eye
Excellent
Stable
Enhancement
Myopia
Hyperopia
Cylinder
Epithelial Ingrowth
Central Island
SightMD to contact patient
Patient will call SightMD
Left Eye
Excellent
Stable
Enhancement
Myopia
Hyperopia
Cylinder
Epithelial Ingrowth
Central Island
SightMD to contact patient
Patient will call SightMD
*
Treatment
Right Eye
Left Eye
Follow up
*
Follow Up
Next Visit in
Right Eye
with co-managing Doctor
with SightMD
1 week
2 weeks
3 weeks
1 month
2 months
3 months
4 months
5 months
6 months
Left Eye
with co-managing Doctor
with SightMD
1 week
2 weeks
3 weeks
1 month
2 months
3 months
4 months
5 months
6 months
Comments
Doctor Signature
*
Date
*
-
Month
-
Day
Year
Date
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