Digital Post-Operative Form

Digital Post-Operative Form

Digital Post-Operative Form

Digital Post-Operative Form

Co-Managing Doctor Information

*Co-Managing Doctor’s Name
*Co-Managing Doctor’s Email Address
A submission receipt will be sent to this email address for your records
Co-Managing Doctor’s Phone Number
City

Patient Information

*Patient's First Name
*Patient's Last Name
*Patient Date of Birth
*Procedure
Date of latest procedure (OD)
Date of latest procedure (OS)

Exam Information

*Post-Op Visit
*Post-Operative Exam Date
Patient’s Symptoms
Current Medications
Uncorrected VA (Distance)
UCVA OU
UCVA OD
UCVA OS
Uncorrected VA (Near)
Near VA OU
Near VA OD
Near VA OS
Tonometry
OD
OS
Manifest Refraction
OD
OS
Cycloplegic Refraction
OD
OS
Slit Lamp Examination
Lids OD
Lids OS
Conjunctiva OD
Conjunctiva OS
Anterior Chamber OD
Anterior Chamber OS
Lens OD
Lens OS
Fundus OD
Fundus OS
Cornea OD
Cornea OS
Cornea Clarity/Edema Grading OD:
Cornea Clarity/Edema Grading OS:
(LASIK ONLY) Interface OD (Presence of Haze):
(LASIK ONLY) Interface OS (Presence of Haze):
(LASIK ONLY) Interface OD (Presence of Debris):
(LASIK ONLY) Interface OS (Presence of Debris):
Additional Notes/Comments
ilovecoastal none 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM Closed Closed Ophthalmologist # # # 363 S Main St, Suite 325, Orange, CA 92868 1524 4th St., Ste 101 Norco, CA 92860 4300 Long Beach Blvd. Ste 400 Long Beach, CA 90807 15825 Laguna Canyon Rd, Ste 201 Irvine, CA 92618 360 San Miguel Dr #307 Newport Beach, CA 92660 https://s3.amazonaws.com/static.organiclead.com/Site-5feee2a5-e131-4578-9b0a-0582c4d8f42e/coastal_vision_website_b-roll_optimized.mp4 Full Width