What's on your clipboard right now?
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Date:_________
Purpose/History:__________________________________________ _______________________________
Care System:__________________________________Wear Time (Now/ Ave/ Max):______/_______/_____
Right Eye Left Eye
Current CTL: Brand:_____________BC:_____Dia:_____Power: OD_______________OS_______________
Entering VA 20/ ____ 20/ ____
Over Refraction __________________________(20/____) __________________________(20/____)
Fit/ FP __________________________________________________ ____________________
Exam __________________________________________________ ____________________
Assessment:_______________________________________ _____________ Order OD:___________________________
__________________________________________________ _________________ OS:____________________________
Doctor:________________________________Next Visit:________________Order CTL (date)___________
Date:_________
Purpose/History:__________________________________________ _______________________________
Care System:__________________________________Wear Time (Now/ Ave/ Max):______/_______/_____
Right Eye Left Eye
Current CTL: Brand:_____________BC:_____Dia:_____Power: OD_______________OS_______________
Entering VA 20/ ____ 20/ ____
Over Refraction __________________________(20/____) __________________________(20/____)
Fit/ FP __________________________________________________ ____________________
Exam __________________________________________________ ____________________
Assessment:_______________________________________ _____________ Order OD:___________________________
__________________________________________________ _________________ OS:____________________________
Doctor:________________________________Next Visit:________________Order CTL (date)___________









Of course you have a clipboard! Whats on it!