Refraction | CV Patient Site

Refraction

Patient # *

Last Name

Date

OBJECTIVE RX -RE

Sphere

CYL

Axis

VA 6 /

6 /

OBJECTIVE RX - LE

Sphere

CYL

Axis

VA 6 /

6 /

Add +

SUBJECTIVE RX - RE

Sphere

CYL

Axis

VA 6 /

6 /

SUBJECTIVE RX - LE

Sphere

CYL

Axis

VA 6 /

6 /

Add +

EDGED RX - RE

Sphere

CYL

Axis

VA 6 /

6 /

EDGED RX - LE

Sphere

CYL

Axis

AV 6 /

6 /

Add +

SVD

Frame #

PD

/

SVN

Frame #

PD

/

Other

Picked up Prescription given for update elsewhere

Other comments