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314-375-2020
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314.375.2020
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About
Meet Dr. Brinton
Meet Dr. Poore
Meet Dr. Lant
Meet Dr. Tersigni
Meet Dr. Chesnut
Media
Careers
FAQs
PRK
BVOA
ICL
Kamra Inlay
SBK LASIK
RLE
Scheduling
SMILE
Affordability
LASIK
Financing LASIK Eye Surgery
LASIK Alternatives
Procedures
Start Here — BVOA
LASIK
Refractive Lens Exchange (RLE)
Visian ICL
KAMRA Inlay
SMILE
PRK laser eye surgery
Testimonials
SBK Testimonials
Toric ICL Testimonials
ICL Testimonials
RLE Testimonials
Bernie Miklasz
PRK Testimonials
SMILE Testimonials
KAMRA Inlay Testimonials
Contact Us
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314.375.2020
Book An Appt
Cancellation/Refund Requests
*Please note that requests require seven (7) business days of processing time.
Please enable JavaScript in your browser to complete this form.
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Step
1
of 5
First and last name
*
Date of birth
*
Appointment are you requesting to cancel
*
BVOA
Surgery
Date and time of this appointment
*
Date
Time
Next
What best describes your reasons for cancelling?
Plan to have LASIK or vision correction surgery with Brinton Vision, just not now
Decided to stay in glasses/contacts long-term
Decided to go to another LASIK provider
What best describes your reasons for cancelling Surgery?
Plan to have LASIK or vision correction surgery with Brinton Vision, just not now
Decided to stay in glasses/contacts long-term
Decided to go to another LASIK provider
Please share why — your feedback is very important to us as we are continuously working to improve the quality of our patient care!
Next
When are you planning to reschedule?
*
In the next three months
Within the next year
I do not know yet
When are you planning to reschedule you surgery?
*
In the next three months
Within the next year
I do not know yet
What is the reason you want to stay in your glasses/contacts??
*
Financial reasons
Fear/Anxiety
Prefer not to say
Are you planning to proceed with a local surgeon practice or national corporate-owned chain?
*
Local surgeon practice
National corporate-owned chain
Prefer not to say
Next
Your BVOA Reservation Fee is good for one year, would you like to
*
Keep it on the books and reschedule later
Just refund my account
When would be a good day to reach out to you to reschedule your surgery?
Which of these other local St. Louis LASIK surgeons have you selected to perform your surgery?
*
Gregg Berdy, MD (Ophthalmology Associates)
Jonathan Crews, MD (Pepose Vision Institute)
Ranjan Malhotra, MD (Ophthalmology Associates)
Jay Pepose, MD (Pepose Vision Institute)
Mujtaba Qazi, MD (Pepose Vision Institute)
Other
Which of the four corporate-owned national chains have you selected?
*
Clarkson
Lasik Plus
Lasik Vision Institute / LVI
TLC Laser Eye Centers
Next
Please select which payment options you used
*
Cash
Check
Credit card
Flexible payment plan - Alphaeon, zero down, 0% interest for 24 months
Flexible payment plan - Alphaeon, 60-month extended payments
Flexible payment plan - CareCredit
Flexible payment plan - GreenSky
Flexible spending account (FSA)
Health reimbursement account (HRA)
Health savings account (HSA)
Other
Indicate the amount you paid with each payment type
*
By checking the box below I acknowledge my understanding of the following:
1) A medical technician will reach out to you shortly to discuss your cancellation
2) Please allow 7 business days of processing time for your cancellation to go through.
3) During this time frame, you may continue to receive confirmation emails for appointments that have not yet been cancelled.
4) For BVOAs cancelled with 48 hours or more of notice, you may retain your BVOA fee as a credit for up to 1 year from the date of your original appointment. No credit is provided for BVOAs cancelled less than 48 hours prior to the appointment arrival time since we schedule only one patient per slot and may not be able to fill your slot on short notice.
I acknowledge that I have read the above
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