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Recommendation & Instruction Form
Patient Name
Room Number
Recommendations - Anti Glare and Scratch Resistance are default
SV Distance
SV Near
SV Computer
Elite Widest PAL
Premium Wide PAL
Standard Progressive (D & N only)
Polarized Sun Glasses
Transitions
Computer PAL
Boost/Anti-fatigue
Bifocal
Miyosmart
1.60: +/- (2-4)
1.67: +/- (4-6.5)
1.74: +/- (>6.50)
CL Ready to Purchase
Comments
Billing
Exams
$99 - Eye Exam
$159 - MTO
$185 - Work
V407
V406
V409
V404
IFHP
V450 ODSP
V451 OW
Partials
OHIP
CL Check
$50 - CL SPH
$60 - CL Toric
$80 - CL MF
$100 - CL Complex
$99 - Urgent Eyecare
$60 - Partial
$45 - Partial
Other Services
$0 - No Charge
$200 - Myopia Management Year
$60 - Myopia Management Visit
$20 - Form Fee
$40 - Visual Field
$60 - Visual Field
Prebook
0
1
1.5
2
3
4
6
Months
Years
Follow Up
Days
Weeks
Months
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