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General Consent On
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Name and relation if not patient signing
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Signature
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PRP
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Focal Laser
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YAG Capsulotomy
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Laser Retinopexy
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LPI
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Vitreolysis
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SLT
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Condition+Procedure for PRP
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Condition for PRP
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Right Eye PRP
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Left Eye PRP
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Drops given
• • •
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Time
• • •
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Area / Pattern
• • •
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Argon Spot size
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Power (mw)
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Total shots
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PLAN
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Additional information
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Condition+Procedure for YAG capsulotomy
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Condition for YAG capsultoomy
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Right Eye YAG
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Left Eye YAG
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Drops given
• • •
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Area / Pattern
• • •
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Power (mj)
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Total shots
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PLAN: YAG capsulotomy
• • •
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Additional information
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Condition+Procedure for LPI
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Condition for LPI
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Right Eye LPI
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Left Eye LPI
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Drops given
• • •
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Area / Pattern
• • •
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Standard power (950mw/4.0mj)
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Atypical power settings
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Total YAG shots
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Total ARGON shots
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PLAN: LPI
• • •
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Additional information
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Condition+Procedure for SLT
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Condition for SLT
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Right Eye SLT
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Left Eye SLT
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Drops given
• • •
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Area of laser
• • •
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Total Shots
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Power (mj)
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IOP 30 min post-laser
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PLAN: SLT
• • •
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Additional information
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Condition+Procedure for Focal Laser
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Condition for Focal laser
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Right Eye Focal
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Left Eye Focal
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Drops given
• • •
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Area of laser
• • •
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Total Shots
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Argon Spot size
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Power (mw)
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PLAN
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Condition+Procedure for Laser retinopexy
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Condition for Laser retinopexy
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Right eye Laser Retinopexy
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Left eye Laser Retinopexy
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Power (mw)
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Argon Spot size
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Total Shots
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Area of laser
• • •
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PLAN: Laser retinopexy
• • •
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PLAN
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Condition+Procedure for vitreolysis
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Condition for vitreolysis
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Right eye Vitreolysis
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Vitreolysis billing OS
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Drops given
• • •
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Area / Pattern
• • •
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Power (mj)
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Total Shots
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PLAN: Vitreolysis
• • •
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PLAN
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