---
title: Wet AMD Injection Refill Form Template with Visual Acuity Tracking | Paperform
description: Streamline wet age-related macular degeneration treatment requests with this specialized form for visual acuity tracking, OCT imaging scheduling, and retina specialist approval workflows.
url: "https://paperform.co/templates/wet-amd-injection-refill-visual-acuity-tracking-form"
type: static
generatedAt: "2026-03-28T00:45:34.933Z"
---

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### Wet AMD Injection Refill & Visual Acuity Tracking Form Template

Managing wet age-related macular degeneration (AMD) requires careful coordination between patients, ophthalmology practices, and retina specialists. This **Wet AMD Injection Refill & Visual Acuity Tracking Form** template helps ophthalmology clinics, retina specialists, and eye care centers streamline the medication refill process while maintaining comprehensive visual health monitoring.

#### Why This Template Matters for Eye Care Professionals

Wet AMD patients require regular intravitreal anti-VEGF injections (such as Eylea, Lucentis, or Avastin) to prevent vision loss. Each refill request should be accompanied by current visual acuity measurements and OCT imaging to help retina specialists make informed treatment decisions. This form replaces scattered phone calls, faxes, and incomplete documentation with a single, comprehensive digital workflow.

With this template, ophthalmologists and retina specialists can:

 - **Capture complete patient and treatment history** in one submission
 - **Track visual acuity changes** over time to monitor treatment effectiveness
 - **Coordinate OCT imaging scheduling** alongside refill requests
 - **Document current symptoms and vision changes** that may indicate disease progression
 - **Facilitate specialist approval workflows** with all necessary clinical information
 - **Maintain accurate medication and dosing records** for compliance and safety

#### Built for Ophthalmology Practices and Retina Specialists

This form is specifically designed for healthcare providers managing wet AMD patients, including:

 - **Retina specialists and ophthalmologists** who need systematic intake of refill requests with clinical data
 - **Ophthalmology clinics and eye care centers** coordinating injection treatments and imaging
 - **Healthcare administrators** managing patient communications and appointment scheduling
 - **Medical assistants and ophthalmic technicians** who collect visual acuity and preliminary data

#### How Paperform Enhances Your AMD Treatment Workflow

Paperform transforms this clinical form into a seamless digital experience that works as hard as your practice does:

**Conditional Logic for Smart Workflows**
The form adapts based on patient responses—if visual acuity has decreased or new symptoms appear, additional questions automatically display to capture critical clinical details for the specialist's review.

**Integrated Scheduling**
Built-in appointment scheduling fields let patients book their OCT imaging session directly within the refill request, eliminating phone tag and reducing no-shows.

**Professional, HIPAA-Conscious Design**
While Paperform is not HIPAA compliant, it offers a professional, branded interface that can be customized to match your practice identity, creating a trustworthy patient experience. For HIPAA compliance, consider using this as an initial coordination tool with secure follow-up via compliant channels.

**Automated Notifications**
When a refill request is submitted, automatic email notifications can alert your retina specialist, schedulers, and pharmacy team—ensuring nothing falls through the cracks.

#### Automate Follow-Up with Stepper

Take your wet AMD management to the next level by connecting this form to [Stepper](https://stepper.io), Paperform's AI-native workflow automation platform. With Stepper, you can:

 - **Route requests** to the appropriate retina specialist based on patient history or urgency
 - **Create tasks** in your practice management system when refills need approval
 - **Send automated reminders** to patients about upcoming OCT imaging appointments
 - **Update electronic health records** with submission data automatically
 - **Track approval status** and notify patients once their prescription is ready

These automations mean less manual data entry for your staff and faster turnaround times for patients who depend on timely treatment.

#### Key Features of This Template

This form includes specialized fields for wet AMD treatment management:

 - **Patient demographics and emergency contact** information
 - **Treating physician and referring doctor** details
 - **Current medication details** (drug name, dosage, injection frequency)
 - **Date of last injection** for treatment interval tracking
 - **Visual acuity measurements** (right and left eye, with Snellen notation)
 - **Symptom assessment** including vision changes, distortion, and blind spots
 - **OCT imaging scheduling** with date/time preferences
 - **Insurance and authorization** information
 - **Pharmacy preferences** for medication fulfillment
 - **Specialist approval section** for internal workflow

#### Who Benefits Most from This Template

This template is ideal for:

 - **Retina specialists** managing large patient panels on anti-VEGF therapy
 - **Ophthalmology practices** coordinating multiple specialists and imaging equipment
 - **Eye care centers** seeking to standardize wet AMD treatment protocols
 - **Medical practices** looking to reduce administrative burden on clinical staff
 - **Healthcare administrators** improving patient communication and satisfaction

#### A Modern Solution for Complex Eye Care

Traditional paper forms, fax machines, and scattered phone messages create delays that can impact patient outcomes. This digital form centralizes the refill request process, ensures all necessary clinical information is collected upfront, and creates a clear audit trail for each treatment decision.

With Paperform's intuitive interface, patients can complete the form from home on any device, while your clinical team receives organized, complete submissions that support efficient specialist review and approval. The result? Faster refills, better monitoring, and improved patient care.

#### Getting Started

This template is ready to customize for your practice. You can modify visual acuity tracking methods, add practice-specific fields, incorporate your branding, and set up notifications that match your internal workflows. Whether you're a solo retina specialist or a multi-provider eye care center, this form scales to meet your needs.

Trusted by healthcare providers worldwide and built with security and compliance in mind, Paperform helps you deliver professional, efficient care coordination. Start streamlining your wet AMD injection refill process today with this purpose-built template.
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