Interim Visit Form

Patient Name *

Date of Visit *

Referring doctor:

If Atropine (perform with most recent eyeglasses on):

DV VACC:

Subjective Refraction:

Nearpoint of accommodation with DV Rx 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​​​​​​​

DV VACC:

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 VACC:

DV Over Refraction (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?

Notes:


Referring doctor Signature:

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