|
Date of Prescription
|
Contact Lens Warning/Expiration
• • •
|
|
Date of Prescription Today?
|
|
|
Brand
|
Sphere OD
|
|
Cyl OD
|
Axis OD
|
|
ADD OD
|
Color(s)
|
|
|
VA cls OD
|
|
Brand
|
Sphere OS
|
|
Cyl OS
|
Axis OS
|
|
ADD OS
|
Color(s)
|
|
|
VA cls OS
|
|
|
VA OU
• • •
|
|
Contact Lens Fit Evaluation
• • •
|
Replacement Schedule
|
|
Rewetting Drops (if needed)
|
Cleaning System
|
|
CLS Rx Status
• • •
|
|
|
|
CLS Waivers
|
