Postop Intake CLRTLC

Step 1 of 3

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Name(Required)

First Last

Date of birth(Required)

MM slash DD slash YYYY

Appointment Time(Required)

AM/PM

Eye Drops Usage

Click on each eye drop you are currently using and indicate how many times per day. *Medication & bottle appearance may vary by manufacturer & pharmacy.

Which eye drops and medications are you taking?

Optase Hylo

Refresh Plus

prednisolone

Durezol/difluprednate

ofloxacin

Bromsite/bromfenac

Prolensa/bromfenac

Ketorolac

timolol

Diamox

Percocet/oxycodone-acetaminophen

vitamin c

None

Other drops

Indicate how frequently you are taking these.

Optase Hylo — Times per day(Required)

Refresh Plus — Times per day(Required)

Prednisolone — Times per day(Required)

Durezol/difluprednate — Times per day(Required)

Ofloxacin — Times per day(Required)

Bromsite/bromfenac — Times per day(Required)

Prolensa/bromfenac — Times per day(Required)

Ketorolac — Times per day(Required)

Timolol — Times per day(Required)

Diamox/acetazolamide — Times per day(Required)

Percocet/oxycodone-acetaminophen — Times per day(Required)

vitamin c — Times per day(Required)

Other drops — Times per day(Required)

Over age 40, as we develop presbyopia, we lose the ability to zoom from far to near.

There are three ways we address this. Which option applies to you:

Describe your vision difficulties.

Describe the difficulties you are having with your distance vision. This is your vision from past your computer monitor to the end of the horizon, and includes street signs, movies, TV, etc.

Note that we expect you to require reading glasses for all near vision tasks as follows:
+1.00 readers for computer distance
+2.00 readers for your watch, dashboard, cell phone, restaurant menu, price tag, and all other activities at this distance
+3.00 readers for threading a needle, tying fishing line, reading small print on a medicine bottle, etc.
+4.00 makeup reading glasses for eye makeup and hygiene

Describe your vision difficulties.

Please list the specific vision issues, if any, that you would like our doctors to address.

I confirm I will arrive 10 minutes early.

Yes

Bring your treatment booklet and all eye drops
Please check in 10 minutes prior to your appointment

Late arrival policy: brintonvision.com/late-arrival-policy