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

Tel: (704) 970-2710 • Fax: (704) 970-2720 • E-mail: arbo@arbo.org

Reference Letters and/or Numbers for Your Personal Use Only:
        (which does not identify the individual patient)
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.

Date: Doctor:
Phone: EMail:

To submit, click the Submit button below or print the form and send or fax it to:

    Arbo
    200 South College St., Suite 1630
    Charlotte, NC 28202
    Fax (704) 970-2720.

 

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