Optometry Exam Room Checklist
Complete this checklist to ensure the exam room is fully prepared for optometry visits. All fields are required for exam-room readiness tracking.
Room Identifier
*
Date of Checklist
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Member Completing Checklist
*
First Name
Last Name
Equipment Readiness
*
Phoropter calibrated
Slit lamp operational
Visual acuity chart functional
Supplies Stocked
*
Disposable gloves
Tissues
Eye drops
Lens/Frames Materials Available
*
Trial lenses present
Frames samples available
Computer/System Readiness
*
Computer powered on
EHR system accessible
Cleaning and Sanitation Status
*
Surfaces disinfected
Hand sanitizer refilled
Notes on Issues or Items Needing Attention
Checklist Completion Confirmation
*
I confirm all required items have been checked and the room is ready for use.
Submit Checklist
Should be Empty: