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Lauderdale, Miami & South Florida
 



 
 

 

 


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		  

 
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Fort Lauderdale and Miami LASIK Specialists
Braverman Eye Center
1935 E. Hallandale Beach Boulevard
Hallandale Beach, Florida 33009
(954) 458.2112  (305) 374-8694          
Refractive Surgery Hotline   (888) 954-LASIK

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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(954) 458-2112 |    (305) 374-8694   |   Refractive Surgery Hotline (888) 954-LASIK

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