EVO ICL Form ICL Post Procedure Care Form PDF Patient Name(Required) First Last Patient’s Birthdate(Required) MM slash DD slash YYYY Co-Managing Doctor(Required)Doctor Phone/Fax(Required)Doctor Email(Required) Procedure(Required)Procedure Date(Required) MM slash DD slash YYYY Target OD(Required) DISTANCE NEAR MONOVISION Target OS(Required) DISTANCE NEAR MONOVISION POST OPERATIVE EXAM AND COMMENTSVisit(Required) 1 week 1 month 3 month MedicationsMedicationFrequency (QID / TID / BID / QD)Eye (OD / OS / OU) Add RemoveUCVA ODUCVA OSSymptoms Blurry Glare Double Fluctuating Vision Other OtherBIOMICROSCOPYAdnexa(Required) Normal Other Lids/Conj/Sclera(Required) Normal Other Cornea(Required) Normal Other Anterior ChamberLensIOP ODPlease enter a number from 0 to 80.IOP OSPlease enter a number from 0 to 80.Date MM slash DD slash YYYY CAPTCHA SMILE Post Procedure Care Patient Name(Required) First Last Patient’s Birthdate(Required) MM slash DD slash YYYY Co-Managing Doctor(Required)Doctor's Email(Required) Doctor's Phone/Fax(Required)Procedure(Required)Procedure Date(Required) MM slash DD slash YYYY Target OD(Required) DISTANCE NEAR MONOVISION Target OS(Required) DISTANCE NEAR MONOVISION POST OPERATIVE EXAM AND COMMENTSVisit(Required) Day 3 or 4 1 month 3 month MedicationsMedicationFrequency (QID / TID / BID / QD)Eye (OD / OS / OU) Add RemoveUCVA ODUCVA OSSymptoms Blurry Glare Double Fluctuating Vision Other OtherAuto RefractionManifest (Dry)BIOMICROSCOPYAdnexa(Required) Normal Other Lids/Conj/Sclera(Required) Normal Other Cornea(Required) Normal Other Anterior ChamberLensIOP ODPlease enter a number from 0 to 80.IOP OSPlease enter a number from 0 to 80.Date MM slash DD slash YYYY CAPTCHA
