|
Client address
|
Client phone
|
|
Contact Lens Expiration Date
|
|
|
Contact Lens RX
|
OD
|
|
POWER
|
BC
|
|
DIA
|
OD CONTACT LENS NAME
|
|
POWER
|
BC
|
|
DIA
|
CONTACT LENS NAME
|
|
OD acuity with rx
|
|
|
OS
|
|
|
POWER
|
BC
|
|
DIA
|
OS CONTACT LENS NAME
|
|
POWER
|
BC
|
|
DIA
|
OS CONTACT LENS NAME
|
|
OS acuity with rx
|
|
|
Recommended CL Solutions
|
CL Replacement Schedule
|
|
Duration
|
CL Follow-Up Needed
|
|
|
Recommendation
|
|
Signature:
|
|
|
Signed by
|
|
|
Certified LV Specialist
|
|
|
NPI number
|
|
|
Return Address
|
Office phone
|
