Blepharitis Discharge Instructions Form
Please complete this form to confirm your aftercare instructions for blepharitis. Review each section carefully and provide accurate information.
Patient Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Blepharitis
*
Anterior
Posterior
Mixed
Other
Prescribed and/or OTC Treatments
*
Home Care Instructions
*
Patient Understanding of Instructions
*
I understand and will follow the instructions
I need further clarification
Follow-up Plan / Next Appointment Details
Submit
Should be Empty: