ANGIOGRAM INTERPRETATION

NAME:

DATE:

PHOTO #:

SSN:

DR:

CLINICAL IMPRESSION:

FUNDUS DESCRIPTION:

OD   OS

OD

OS: 

OD

Red-Free: 

Pre-Injection: 

Arterial: 

A-V: 

Venous: 

Recirculation: 

Late: 

OS

Red-Free: 

Venous: 

Recirc: 

Late: 

Impression

Plan

PHYSICIAN:

DATE:

12/4/2012

STAFF: