a Date and Time Relationship to Patient

2270 2nd Floor Endriga Bldg, Taft Avenue, Brgy. 725, Zone 079, Malate, Manila 1004
Tel no. (02)522-1144

Patient’s Name:___________________________________Age:_____Sex:_____ Date:_________

PSEUDOPHAKIA __
_______POSTERIOR CAPSULAR OPACITY_________________________________________
PRE – OPERATIVE DIAGNOSIS

_______YAG CAPSULOTOMY _____________________________________________________

OPERATION DONE
P/S YAG CAPSULOTOMY____

_______PSEUDOPHAKIA_________________________________________________________
POST – OPERATIVE DIAGNOSIS

_________________________ __________N/A_____________
SURGEON ASSISTANT

________________________ ____________________________
SCRUB NURSE CIRCULATING

ANESTHESIA:____TOPICAL____________

ANESTHESIOLOGIST:___________________________ Time: ___________

OPERATIVE TECHNIQUE DATE:______________________

 Topical anesthesia instilled on ____.

 Patient in sitting position.
 Yag Cap lens placed.
 Yag Cap settings under the Slit Lamp.
Power ____________
Aiming beam __________ Pulse__________________
 Laser Yag Cap done.
 Topical steroid instilled.
 Patient tolerated the procedure well.

_______________________, M.D.
License No. __________
Doctor’s Signature