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Treehouse Eyes Myopia Treatment – Interim Visit Form

Patient:
Referring doctor:
MM slash DD slash YYYY

If Atropine (perform with most recent eyeglasses on):

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

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):

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?
x

We are fully booked for general eye exams for the year 2022. Our next available eye exam is in Jan 2023. We apologize for the inconvenience. If you have a valid glasses or contact lens prescription, please give us a call or text us to make arrangements. If you have questions regarding your child’s myopia, please give us a call at (408) 502-7636 to talk to our myopia counselor.