Treehouse Eyes Myopia Treatment – Interim Visit Form Patient: First Last Referring doctor: First Last Date of Visit: MM slash DD slash YYYY If Atropine (perform with most recent eyeglasses on):DV VA CC ODDVA CC OSSubjective RefractionNearpoint of accommodation with DV Rx on = inchesIf 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 LensesDV VA CC ODDVA CC OSSubjective 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 VA CC ODDVA CC OSDV Over Refraction (lenses ON) ODDV Over Refraction (lenses ON) OSDV Over Refraction (lenses ON) OUIf 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:ODOSIf CL wearer, wear/care/wearing schedule reviewed? Yes No Notes:Referring doctor signature: Δ
