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Refractive Surgery Consult Form
An Active Duty Only Program DEC 2018SECTION 1.
Last Name:
First Name:
Rank:
Age:
DOB (mmddyyyy):
DOD ID:
Home email:
Work email:Unit:
Unit Zip:
Work Tel:
Mobile Tel:
End
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How to fill out refractive surgery consult form
How to fill out refractive surgery consult form
01
Start by gathering all the necessary information such as personal details of the patient including name, age, contact information, and address.
02
Include the patient's medical history, including any past eye surgeries, current medications, and any pre-existing conditions.
03
Ask the patient about their current vision problems and reasons for seeking refractive surgery.
04
Include detailed information about the patient's visual acuity, covering both near and distance vision.
05
Ask the patient if they have any allergies or sensitivities to medications or anesthesia.
06
Include a comprehensive eye examination section, covering tests such as corneal topography, intraocular pressure measurement, and retinal examination.
07
Include a section to record the patient's expectations and desired outcomes from the refractive surgery.
08
Provide a space for the patient to ask any questions or express concerns about the procedure.
09
Finally, ensure that the form includes the patient's signature, indicating their consent to proceed with the refractive surgery.
Who needs refractive surgery consult form?
01
Anyone who is considering undergoing refractive surgery should fill out the refractive surgery consult form.
02
Patients who are experiencing vision problems and want to explore the option of refractive surgery as a treatment should also complete this form.
03
It is also important for individuals who have a history of eye surgeries or any pre-existing eye conditions to fill out the form.
04
The form helps the healthcare provider assess the suitability of refractive surgery for the patient and gather all the necessary information for a successful procedure.
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What is refractive surgery consult form?
The refractive surgery consult form is a document used to gather information about a patient's eligibility and suitability for refractive surgery.
Who is required to file refractive surgery consult form?
Patients who are considering undergoing refractive surgery are required to fill out the consult form.
How to fill out refractive surgery consult form?
Patients can fill out the consult form by providing accurate information about their medical history, current medication, and previous eye conditions.
What is the purpose of refractive surgery consult form?
The purpose of the refractive surgery consult form is to assess the patient's overall health and determine if they are a good candidate for refractive surgery.
What information must be reported on refractive surgery consult form?
Information such as medical history, current medication, previous eye conditions, and contact information must be reported on the consult form.
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