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Checked out by:
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OK TO LOCK CHART
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Billing
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EXAM BILL
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Bill Medical
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Fitting & Supply
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Vision Insurance
• • •
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Follow Up
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Email Glasses RX
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Review Asked & Sent?
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Referral Asked?
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Schedule DFE
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DFE Scheduled?
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Schedule VFE/OCT
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VFE/OCT Scheduled?
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Photos
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Photos Charge
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Topography
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Topo Charge
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Gonioscopy
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Gonioscopy Charge
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Exam/ Copay
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DMV Test
• • •
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Fitting/Copay
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Contact Supply Price
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Allowance/Discount
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Contact Amount Paid
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Additional Charges
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Total Amount Paid
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To Be Ordered
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Wearing Contact RX
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Trials Dispensed Today #1
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Trials Dispensed Today #2
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Order Contacts
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Brand of Contacts
• • •
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Base Curve
• • •
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OD Sph
• • •
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OD Cyl
• • •
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OD Axis
• • •
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Wearing Add
• • •
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OS Sph
• • •
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OS Cyl
• • •
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OS Axis
• • •
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Wearing Add
• • •
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Total Supply Ordered
• • •
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ORDERED
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Vendor Ordered From
• • •
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Ship to Patient
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Order Notes
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Wearing Spec RX
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Manifest RX
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Final Spec RX
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Frames
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Pair #
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Brand
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Model
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Frame Color
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Eye/Bridge
/
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Order New Frame
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Lens Order
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Lens Type
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Lens Material
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Anti Reflective/ Transitions
• • •
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Addition Notes
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Additional Notes
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RX Glasses
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RX Contacts
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