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ODOS VISION St. Johns Town Center
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DOB
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Patient Name and Exam Date
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Glasses: Use Final Rx?
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Special Recomendations
• • •
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Glasses: Use Subjective 2/Trial Frame?
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Special Recomendations
• • •
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Additional instructions or comments
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New CL RX
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Contacts: Same brand OU?
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Replacement:
• • •
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Contacts: Different brand OD, OS?
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Replacement:
• • •
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Second Contact Lens Rx?
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Replacement:
• • •
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CL instructions/comments (will print on RX)
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Spectacle Rx Expires 2 yeas
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Additional CL expiration options (Due to Covid)
• • •
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CL Expiration 1 YR
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CL Expiration 2 YRS
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SOVA Electronic Signature:
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MOCANU Electronic Signature:
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KNABB Electronic Signature:
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