POST PROCEDURE CARE - PRK
SightMD PRK POST PROCEDURE CARE
SightMD PRK POST PROCEDURE CARE
Patient Name
*
First Name
Last Name
Co-Managing Doctor
*
First Name
Last Name
Assistant
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
Jordan Garelick, MD - Brentwood
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 PRK
Custom
Conventional
Enhancement
Plano
Mono
Left Eye
Primary PRK
Custom
Conventional
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
Corneal Clarity
*
IOP (app.tonometry)
Haze Grade
Haze Pattern
Right Eye
Clear
Trace Reticular
Mild Reticular
Moderate Confluent
Severe Confluent
Diffuse
Focal
Arcuate
Left Eye
Clear
Trace Reticular
Mild Reticular
Moderate Confluent
Severe Confluent
Diffuse
Focal
Arcuate
*
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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