Easysclereal Adjust Form

Adjust Easyscleral Lenses

Easy Scleral Adjustment

Patient Name/Ref

Account ID

Prescriber Name

PO Number

Adjustment Calculation (Single Lens)

Assessed EasyScleral SAG (µm)

Assessed BOZR (mm)

Assessed Lens Power

Sphere

Cyl

Axis (°)

Flat Axis Orientation (°)

ORIENTATED LENS POWER

Sphere

Cyl

Axis (°)

Over-refraction

OR Sphere

OR Cyl

OR Axis (°)

RESULTANT POWER INCORPORATING OVER-REFRACTION

Sphere

Cyl

Axis

Eye & Material

EasyScleral SAG to Order (µm)

BOZR at Ordered SAG (mm)

Scleral Angle

Custom Limbus

Lens Power Sphere

Lens Power Cyl

Lens Power Axis (°)

Notes/Order Statement

Captcha