Treehouse Eyes Myopia Treatment – Interim Visit Form Patient: First Last Referring doctor: First Last Date of Visit: MM slash DD slash YYYY 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 LensesDV 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:OD OS If CL wearer, wear/care/wearing schedule reviewed? Yes No Notes: Referring doctor signature: