Fillable Commonwealth of Massachusetts Optometrists RX Check Form

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Commonwealth of Massachusetts Optometrists RX Check Form

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The Commonwealth of Massachusetts Optometrists RX Check Form form is 1 page long and contains:

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File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Patient Problem Tracking Form for Optometrists Who
Have Regular Business Relationships with Opticals
Patient: _____________________________ Optician/OD
Original Rx Date: _____________________ Date: ______________________________
Patient’s Reported Problem:
_____________________________________________________________________________
_____________________________________________________________________________
Previous Rx if available New Rx
Rx age ________________________________ _________________________
Doctor ________________________________ _________________________
Lens material ________________________________ _________________________
PD,CT,BC ________________________________ _________________________
Seg/Lens Type ________________________________ _________________________
Seg Height ________________________________ _________________________
Coating ________________________________ _________________________
Frame Adjust ________________________________ _________________________
Decentration/Prism ____________________________ _________________________
Procedure Complete Performed Comments Date
Yes or No by
Adjustment
Fabrication error/Rx remade
New Rx Dispensed
Pt not satisfied/Apt with Doctor
Second exam findings
New Rx dispensed with changes
Doctor/Optician 2 week
Satisfaction call
Other
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Commonwealth of Massachusetts Optometrists RX Check Form

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Completed 15 May 2020

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