Myopia Co-management Form Please click here to schedule a 15 minute zoom meeting to learn about co-management. Please click here for 6 months follow up visit co-management form PatientDate of Birth MM slash DD slash YYYY Gender M F Parent’s Name First Last Email PhoneParent’s preferred contact method email phone The patient’s parent has had their questions answered regarding the consequences of treating versus not treating their child’s myopia (for example, possible eye health implications of increasing myopia).* Yes No Ethnicity Asian Black Latino Caucasian Patient has been myopic for approximately (years)Parents myopic Yes No Who Mother Father Siblings myopic Yes No How many myopic siblings VA sc: OD: 20/OS: 20/Current Subj Rx: OD:20/OS:20/Previous Rx: (date) MM slash DD slash YYYY OD: 20/OS: 20/Estimated digital device useEstimated time outdoorsReferring DoctorDoctor’s email Will you be co-managing Yes No Δ
