YAG Posterior Capsulotomy Referral Form

Title, First Name, Last Name and Suffix

Patient Info

Patient reports to Valley Surgery Center for procedure. Women should not wear eye make-up and ALL patients should arrange for someone to drive them home after the procedure.

First Name
Last Name

Patient Evaluation is Completed

I request a YAG Posterior Capsulotomy based on the following clinical findings and patient complaints:

Please check all that apply. Patient complaints must be noted to meet YAG PC medical necessity.