ULTRASONOGRAPHY RECAPITULATION

N DATE NO. MR Patient Name

O

10

Department of Ophthalmology, Airlangga University Cataract Portofolio

Page ……….
ULTRASONOGRAPHY NO. ………..

Name :
No. MR :
Date :

Result OD OS
Retina :
Corpus Vitreous :
AXL :
Conclusion :

Verificator,

( )

ULTRASONOGRAPHY NO. ………..

Name :
No. MR :
Date :

Result OD OS
Retina :
Corpus Vitreous :
AXL :
Conclusion :

Verificator,

( )

Department of Ophthalmology, Airlangga University Cataract Portofolio

Page ……….
ULTRASONOGRAPHY NO. ………..

Name :
No. MR :
Date :

Result OD OS
Retina :
Corpus Vitreous :
AXL :
Conclusion :

Verificator,

( )

ULTRASONOGRAPHY NO. ………..

Name :
No. MR :
Date :

Result OD OS
Retina :
Corpus Vitreous :
AXL :
Conclusion :

Verificator,

( )

Department of Ophthalmology, Airlangga University Cataract Portofolio

Page ……….