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Demographic and Medical History

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  • Demographic and Medical History

Personal Information

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Gender(Required)
Are You Military?(Required)
Do you have vision insurance?(Required)

Emergency Contact Information:

10 Questions to Learn About You

1. Tell us about your contact lens usage:

Do you wear contact lenses?(Required)
Do you sleep in your contacts?(Required)
What type of contacts do you wear?(Required)

2. Please tell us about your work:

Is your work mostly?(Required)
Do you:(Required)

3. Please tell us about your Leisure Activities:

Do you participate in any of the following activities:(Required)

4. Is there a particular type of vision correction procedure you're interested in having?

I'm interested in:(Required)

5. Tell us more about your needs and preferences for your vision:

How much driving do you do at night?(Required)
If you're over 43, what kind of near vision would you prefer?(Required)
Please select a number to describe your personality.(Required)

6. Please tell us about your eye history:

Do you have any of the following?(Required)
Do you currently use eye drops?(Required)

7. Please tell us about your medical history:

Have you had any non-eye surgeries?(Required)
Have you had or do you presently have any of the following conditions?(Required)
For Women Only:
Do you take any medications?(Required)

8. Allergies:

Are you allergic to the following?(Required)
Are you allergic to any medications?(Required)

9. Please list any questions or concerns that you want to make sure we cover at your appointment:

10. Referral Info:

“I wish I’d done it sooner!”

The number one thing we hear from our patients is that they wish they’d had LASIK sooner.

So the question for you is… why wait any longer?

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  • 7101 NW Expressway
  • Suite 335
  • Oklahoma City, OK 73132
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  • Phone: 405.733.2020
  • Fax: 405.721.1411
  • Mon-Fri 8am-5pm
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