|
Date of Prescription
|
Dispensed Trials
|
|
Contact Lens Warning/Expiration
• • •
|
Dispensed By:
|
|
|
TRIALS
|
|
Brand
|
ADD OD
|
|
Sphere OD
|
Cyl OD
|
|
Axis OD
|
Color(s)
|
|
|
Visual Acuity OD
|
|
Brand
|
|
|
Sphere OS
|
Cyl OS
|
|
Axis OS
|
Visual Acuity OS
|
|
ADD OS
|
|
|
|
|
|
Contact Lens Fit Evaluation
• • •
|
Color(s)
|
|
Replacement Schedule
|
STATUS
|
|
Rewetting Drops (if needed)
|
Cleaning/Storage Solution
|
