PATIENT INFORMATION SHEET NAME __________________________________ DATE _______________________ ADDRESS _______________________________ PHONE (DAY) ________________ CITY/STATE/ZIP _________________________ (NIGHT) _____________________ OCCUPATION ___________________________ COMPANY __________________ EMAIL __________________________________ AGE ___ BIRTHDATE ________ CURRENT EYE DOCTOR ________________________________________________ Please answer the following questions to help us determine what type of candidate you are.
How were you referred to Beyer Laser Center? _________________________________ Why are you looking at laser vision correction? ________________________________ _______________________________________________________________________ How long have you been thinking about laser vision correction? ___________________ Do you wear glasses or contacts? ___________________________________________ If contacts, what kind? ____ Soft ____ Soft Toric ____ Gas Perm (RGP) ____ Hard Last time worn ______________________________________________ How old is your prescription? ______________ What is your satisfaction with your glasses or contacts? Best 10 9 8 7 6 5 4 3 2 1 Worst
Comments ____________________
What are your hobbies or interests? __________________________________________ Patient Signature _______________________________ Date __________________ OFFICE NOTES: Recommendation:
RX: OD ______________________ OS ______________________ Add ____________ Vcc OD _______ OS _______ Vsc OD _______ OS _______
PRICE QUOTED: ____________
Pupil Size OD ______ OS ______
Beyer Laser Center, LLC 1810 30th St., Ste. B Boulder, CO 80301 Tel. (303) 499-2020 Fax (303) 554-5846