MYOPIA TREATMENT CO-MANAGEMENT FORM

MM slash DD slash YYYY
Gender :(Required)
The patient’s parent has had their questions answered regarding the consequences of treating versus their child’s myopia (for example, possible eye health implications of increasing myopia).(Required)
Ethnicity:(Required)
years
Parents myopic:
Who:
Sibling’s myopic:
VAsc:
Current Subj Rx:
MM slash DD slash YYYY
)
hrs/day
hrs/day
Will you be co-managing: