Treehouse Eyes Myopia Treatment – Interim Visit Form

Patient:

First Last

Referring doctor:

First Last

Date of Visit:

If Atropine (perform with most recent eyeglasses on):

DV VA CC OD

DVA CC OS

Subjective Refraction

Nearpoint of accommodation with DV Rx on = inches

If above Subjective Refraction (SR) in either eye is ≥ -0.50 D compared to last SR, refer to Treehouse Eyes for further evaluation.

If Custom Soft Multifocal Lenses

DV VA CC OD

DVA CC OS

Subjective Refraction (lenses off, NOT an OR):

If above Subjective Refraction (SR) in either eye is ≥ -0.50 D compared to last SR, refer to Treehouse Eyes for further evaluation.

If Custom Overnight Treatment Contact Lenses (perform with lenses on):

DV VA CC OD

DVA CC OS

DV Over Refraction (lenses ON) OD

DV Over Refraction (lenses ON) OS

DV Over Refraction (lenses ON) OU

If OU VA with over refraction is < 20/30, refer to Treehouse Eyes for further evaluation.

If no referral to Treehouse Eyes is required, recall patient to your practice for ongoing comprehensive care at your customary recommended interval (usually about one year since the last comprehensive examination).

SLE:

If CL wearer, wear/care/wearing schedule reviewed?

Yes

Notes:

Referring doctor signature:

Treehouse Eyes Myopia Treatment – Interim Visit Form

If Atropine (perform with most recent eyeglasses on):

If Custom Soft Multifocal Lenses

If Custom Overnight Treatment Contact Lenses (perform with lenses on):

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