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:

  •   Select if patient did not show up for scheduled appointment
      Left message for patient to reschedule
      Unable to contact patient
  • PRE-OP Rx:
  • VA: 
  • VA: 
  • OD Intended Procedure Outcome: (leave blank if none)
  •   AIM 
  • OS Intended Procedure Outcome: (leave blank if none)
  •   AIM 
  • Post-Op Information:
  • 20 /
    20 /
    20 /

  •      x      ==> 20/

  •      x      ==> 20/
  • OD SL Exam:
  • OS SL Exam:
  • TaG (After 1 week):
  •  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

  • RV:        With BEC     With Co-care provider

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