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314-375-2020
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314-375-2020
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Postop Intake
Please complete this quick form before your appointment tomorrow.
Name
(Required)
First
Last
Date of birth
(Required)
MM slash DD slash YYYY
Appointment Time
(Required)
HH
:
MM
AM
PM
AM/PM
Vision Concerns
Please list the specific vision issues, if any, that you would like our doctors to address.
Eye Drops Usage
Click on each eye drop you are currently using and indicate how many times per day.
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
Indicate how frequently you are taking these.
Optase Hylo — Times per day
Refresh Plus — Times per day
Prednisolone — Times per day
Durezol/difluprednate — Times per day
Ofloxacin — Times per day
Bromsite/bromfenac — Times per day
Prolensa/bromfenac — Times per day
Ketorolac — Times per day
Timolol — Times per day
Diamox/acetazolamide — Times per day
Percocet/oxycodone-acetaminophen — Times per day
vitamin c — Times per day
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
Have you had LASIK or lens implant surgery in the past?
Yes
No