Laser Vision Correction Post-Op Form

Use the following form to submit reports on LASIK/ EPI-LASIK or PRK procedures. The submitted form will be automatically sent to the Braverman Eye Center. You will also be able to print a copy for your records after submitting the form.

Please complete all applicable form fields:

Co-managing OD/MD:
Patient Name:(last name first)
Age:
Procedure:
Procedure Date OD:
Procedure Date OS:
Select if patient did not show up for scheduled appointment
Left message for patient to reschedule
Unable to contact patient
PRE-OP Rx:
OD: VA:
OS: VA:
OD Intended Procedure Outcome: (leave blank if none)
OD AIM
OS Intended Procedure Outcome: (leave blank if none)
OS AIM
Post-Op Information:
Assessment Date
Binocular UCVA 20 /
OD UCVA 20 /
OS UCVA 20 /
OD Manifest * (if no cyl, select 0)
x ==> 20/
OS Manifest * (if no cyl, select 0)
x ==> 20/
OD SL Exam:
Surface
Flap Position
Clarity
Interface
Edges
OS SL Exam:
Surface
Flap Position
Clarity
Interface
Edges
TaG (After 1 week):
OD mm. Hg. OS mm. Hg.
Alert Issues - (If present, must include in alert issue comments below)

Dissatisfaction Issues
Nighttime Halos/Ghost
Glare/Light Sensitivity
Significant DES/SPK
Mono V Adapt Difficulty
Loss BCVA 1 line or more

Epi Ingrowth
Visually Significant Striae
DLK Peripheral
DLK Visual Axis
Recurrent Erosion

Alert Issue Comments:
Medications:
Patient/Doctors Comments:
Follow Up:
RV: With BEC With Co-care provider
Leave this field blank:

The surgeons of Braverman Eye Center are well known as South Florida, Ft. Lauderdale and LASIK Miami specialists. These renowned surgeons have also helped many Ft. Lauderdale and Miami cataract surgery patients enhance their vision. When you think of Miami cataracts or Miami LASIK, think of Braverman Eye Center.

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Laser Vision Correction Post-Op Form

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