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Selected
Account Number
Order Type
Patient Name
Eye
One/two Eyes

Trial Lens Used

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Lens Design
Diameter
SAG
Base Curve
Lens Power
Material
Color
Add-Ons
Modifications Requested

Fitting information AT INSERTION

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Central Clearance
Limbal Clearance
Scleral Alignment
Rotation
ORX

Please notate if applicable

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Impingement
Edge Stand-Off
Pinguecula
Limbal Curve indicator (temporal)
Observations / Modifications
Notes

Trial Lens Used (right)

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Lens Design (right)
Diameter (right)
SAG (right)
Base Curve (right)
Lens Power (right)
Material (right)
Color (right)
Add-Ons (right)
Modifications Requested (right)

Fitting information AT INSERTION (right)

—————

Central Clearance (right)
Limbal Clearance (right)
Scleral Alignment (right)
Rotation (right)
ORX (right)

Please notate if applicable (right)

—————

Impingement (right)
Edge Stand-Off (right)
Pinguecula (right)
Limbal Curve indicator (temporal) (right)
Observations / Modifications (right)
Notes (right)

Trial Lens Used (left)

—————

Lens Design (left)
Diameter (left)
SAG (left)
Base Curve (left)
Lens Power (left)
Material (left)
Color (left)
Add-Ons (left)
Modifications Requested (left)

Fitting information AT INSERTION (left)

—————

Central Clearance (left)
Limbal Clearance (left)
Scleral Alignment (left)
Rotation (left)
ORX (left)

Please notate if applicable (left)

—————

Impingement (left)
Edge Stand-Off (left)
Pinguecula (left)
Limbal Curve indicator (temporal) (left)
Observations / Modifications (left)
Notes (left)

Attached Files

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Attached Files

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Narre Warren Vic 3805

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