To Make an Appointment

Please fill out our Pre-Operative Questionnaire. Remember, vision correction procedures are open to individuals at least 18 years of age or older, so be sure you (or the person you have in mind) are eligible.

Note: Please make sure the form is completely filled out.

If you prefer, you may call us so we can answer your questions over the phone. When you call the office, please give the receptionist a brief description of your problem so that it can be handled appropriately. If you need to speak with Dr. Belmont, she will return your call at her earliest convenience.

Pre-Operative Questionnaire
All information is confidential and will not be shared
Name(Last, First, MI):
Birthdate:
Month Day Year
Age:
Occupation:
Address:
City: State:
Zip: Country:
Phone Number:
Email:
Employer:
How did you hear about us?
 
If a doctor suggested you see us, please provide this information:
Dr's Name:
Phone:
Address:


Why are you interested in vision correction?(Check all that apply)
I dislike wearing glasses. Eyeglasses and contacts are inconvenient for sports and recreation.
I dislike my appearance with eyeglasses. I hope to undertake a career that requires good vision (police, fire, etc.)
Contact lenses are irritating or uncomfortable. I am concerned about functioning in an emergency.
Contact lenses are inconvenient. I want freedom from dependency on artificial devices.
Other reasons:
   
Medical and Eye History
With eyeglasses or contacts on, how much nighttime glare or halos do you have? None  Minimal  Mild 
Moderate  Severe 
List all eye surgeries, injuries or diseases you have had:
List all medical problems you have:
List all eyedrops you use, which eye, and how often you use them:
List any medication you are allergic to:
If female, are you or might you be pregnant? Yes     No
Comments or Questions:



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