|
Condition for procedure
|
|
|
Avastin Right Eye
|
Eylea Right Eye
|
|
Avastin Left Eye
|
Eylea Left Eye
|
|
Avastin Both Eyes
|
Eylea Both Eyes
|
|
LOT NUMBER
|
EXPIRATION
|
|
Name and relation if not patient
|
|
|
New Field
|
|
|
New Free Draw
|
|
