Complication(s) due to Contact Lenses
Dispensed without a Valid Prescription
Reporting Form

Symptoms:  
Burning Dry Eye
Conjunctivitis Foreign Body Sensation
Corneal Distortion GPC
Corneal Edema Itching
Corneal Epithelial Defect Keratitis
Corneal Infiltrate Neovascularization/Pannus
Corneal Opacity Ocular Inflammation
Corneal Ulcer Pain
Discharge Stinging
Other  
 
Treatment Plan: Outcome:
Lubricants Return to Pre-Incident Status
Antibacterial Topical/Oral   Long Term but Not Permanent Vision Loss
Antibacterial/Anti-Inflammatory Topical/Oral Permanent Vision Loss
Surgical Intervention Penetrating Keratoplasty
Other Other

Financial Impact to Patient/Health Care Resources Utilized
Medical Costs (Out of Pocket)   $
Medical Costs (Third Party Payer)   $
Sick Days Lost   $
Loss of Income due to Office Visit, $
    Total or Partial Disability, etc.
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State/Province: (required)   

Date: Doctor:
Phone: E-Mail:

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