Booking Surgery cancel new

while booking surgery cancelation with new appt 2026-10-21

surgery cancelation checklist (no new booking)

"*" indicates required fields

booking TECH's bv email address*

patient preferred first name*

patient last name*

Please verify your personal cell phone number and best email address. [patient needs to verbally confirm]

patient personal cell number*

patient best email here*

patient dob*

I confirm that the patient name, phone number and email are correct and match in hubspot and acuity*

Yes

surgery cancelation checklist (no new booking)

PATIENT SAFETY CHECKLIST
We certainly understand that plans and circumstances can change. We appreciate the trust you've placed in Brinton Vision and want to make sure we understand your decision and address any concerns you may have. Would you mind sharing what's prompting you to reconsider your surgery at this time?

Thank you for sharing that with me. I completely understand, and I appreciate you taking the time to explain. We want you to feel comfortable and confident in your decision. If there's anything we can do to address your concerns, we'd certainly welcome the opportunity. Otherwise, I'm happy to help you with the next steps.

whoever processes the cancellation is responsible to ensure these steps are done. *All of these must be checked off before continuing .**

Did you use financing? if no, skip to next step. if yes: When you first scheduled your surgery and agreed to start the financing, at that point we lose access since it becomes a private loan between you and Alphaeon/CareCredit. For financial security and privacy reasons, we aren't allowed any more visibility to your loan with them. We are happy to push a full refund right away, which can take up to 10 business days to fully travel through the system, and they will honor this, but we have no information on financing charges, interest payments, late payments, and other similar payments which go directly to Alphaeon/CareCredit and not us. These cannot be refunded by us; we have no visibility or access to them anyway. Be sure and make any payments on time until the refund has moved through the system and you have received your funds back so you avoid any charges from the company, or you are welcome to speak directly with them about this. Do you have any questions about how a refund works with financing?*

Yes

whoever processes the cancellation with new booking is responsible to ensure these steps are done*

move acuity surgery and post-op appointments to the desired date

move future tasks to align with new surgery date

confirm patient has drops; if new surgery date is sooner and no drops, remind patient to call juniper

document in hubspot

while booking surgery cancelation with new appt 2026-10-21

surgery cancelation checklist (no new booking)

whoever processes the cancellation is responsible to ensure these steps are done. ***All of these must be checked off before continuing .****

Have you had LASIK or lens implant surgery in the past?

whoever processes the cancellation is responsible to ensure these steps are done. *All of these must be checked off before continuing .**