POST PROCEDURE CARE - PRK
SightMD CT PRK POST PROCEDURE CARE
SightMD CT 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
Leslie Doctor, MD - Norwalk
Leslie Doctor, MD - Westport
Leslie Doctor, MD - Wilton
Steve Tu, DO - Enfield
*
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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