SPECIAL FX CONTACT LENS PATIENT INFORMATION

(To be completed by an Optometrist or licensed optician)

Yes No

Soft
Gas Permeable
PMMA

History of dry eyes?
Allergies?

Glasses Prescription VA@ 6M Add VA@40cm
OD: 20/ +
OS: 20/ +
Keratometry  
OD: steep: D flat: D@ (axis)
OS: steep: D flat: D@ (axis)

clear
distorted

Anterior Segment

Vertical : mm Horizontal : mm

Cornea: (any distortion or staining?)
Conjunctiva: (any follicles, papillae?)
Anterior Chamber :

Diagnostic CL Fitting

Please trial fit with one of the following base curves in a 15.0 diameter, mid-water content soft lens (55%). Please check the best base curve for each eye.

8.3
8.6
8.9

8.3
8.6
8.9

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