New Document

Name

E-mail address

Date of birth

Height

Weight

Sex Male Female

Home phone

Work phone

Cell phone

Address

City

State

Zip

Driver's License #

Occupation

Emergency Contact

Preferred Appointment Date

Have you had a previous Lasik Consultation, When and Where?

Are you using any type of Insurance or discount program for the LASIK? YES NO

Are you using any financing? YES NO

How did you hear about our Clinic?

I was seen at a Nationwide Vision Center

Radio advertisement (please list station)

Newspaper advertisement (please list newspaper)

I received a letter in the mail

I was referred by another patient (please list name)

Other (please describe)

Do you have any of the following medical conditions? Please check all that apply.

Diabetes

High Blood Pressure

HIV

Chest Pain

Rheumatoid Arthritis

Pacemaker

Hepatitis

Emphysema or Asthma

Lupus Erythematosis

Seizures

Pregnant or nursing (Within the last six months)

Herpes

Are you allergic to any medications? YES NO

Are you sensitive to or allergic to surgical tape / Latex products / Iodine ? YES NO

Do you smoke? YES NO

Please list all past and current medical conditions (ex: high blood pressure). If none, please write "none":

Please list all current medications (including oral contraceptives, hormones and over-the-counter medications). If none, please write "none":

When was your last eye examination?

Where?

Did your doctor discuss LASIK with you? YES NO

Have you ever had eye surgery for any reason? YES NO

Do you have a history of eye disease? YES NO

Please list all current eye drops that you use and how often you use them. If none, please write "none":

Do you wear contact lenses: YES NO

Please check what kind:

Soft disposables

Soft daily wear

Soft extended wear

Soft torics (for astigmatism)

RGP's (hard lenses)

Unsure of type

Do you ever sleep in your contact lenses? YES NO

When did you last wear your contact lenses? Please list date

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