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Checked out by:
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OK TO LOCK CHART
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EXAM BILL
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Fitting & Supply
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Bill Medical
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Vision Insurance
• • •
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Schedule DFE
|
DFE Scheduled?
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Schedule VFE/OCT
|
VFE/OCT Scheduled?
|
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Photos
|
Photos Charge
|
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Topography
|
Topo Charge
|
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Gonioscopy
|
Gonioscopy
|
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DMV Test
• • •
|
Exam/ Copay
|
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Additional Charges
|
Fitting/Copay
|
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Contact Supply Cost
|
Insurance Allowance
|
|
Contact Amount Paid
|
Total Amount Paid
|
|
Total Supply Ordered
• • •
|
Ship to Patient
|
|
Order Notes
|
|
|
Order Trials
|
Order Contacts
|
|
|
|
|
|
|
|
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|
|
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|
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Brand of Contacts
• • •
|
Base Curve
• • •
|
|
OD Sph
• • •
|
|
|
OD Cyl
• • •
|
|
|
OD Axis
• • •
|
Wearing Add
• • •
|
|
OS Sph
• • •
|
|
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OS Cyl
• • •
|
|
|
OS Axis
• • •
|
Wearing Add
• • •
|
|
ORDERED
|
|
|
RX Glasses
|
RX Contacts
|
