1

Low Myopia & After LASIK baseline examination form

Date of birth: Patient name:

Patient Phone: Patient home address:

Patient gender Patient email

Treated Eye Left Right Both

Present Rx Type Glasses CL None

Mark the correct box

Current Spectacles Rx SPH CYL AXIS ADD

Distance RE
LE

# missed
Subjective Refraction SPH CYL AXIS BCVA letters

Distance RE

LE

# missed letters
UCVA Distance RE
LE

Info@revitalvision.com Main office: +972 (77) 212 3272 / USA Phone: +1 (785) 856-0417 www.revitalvision.com

V1 Doc # EF3 08/10/2020

 2

FACT SINE WAVE CONTRAST TEST (Optional)

RE LE

Is there any ocular disease? Yes/No Date of examination: ___________________________

Please detail: __________________________________________________________________________________

Name of practitioner: ________________________________________ Signature: __________________________

Clinics contact number: _______________________________ E-mail: ____________________________________

Low Myopia & After LASIK periodic follow up examination

# missed letters

UCVA Distance RE
LE

FACT SINE WAVE CONTRAST TEST (Optional)

RE LE

V1 Doc # EF3 08/10/2020

Name of practitioner: ________________________________________ Date: __________________________

Info@revitalvision.com Main office: +972 (77) 212 3272 / USA Phone: +1 (785) 856-0417 www.revitalvision.com