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The Brinton Vision Ocular Analysis process is focused on YOU, and this form is the first step. Our team is caring, detailed, and thorough as we work with you to achieve your vision goals. This form asks specific questions – we appreciate your complete responses. This form should take about 15 minutes to complete. We recommend using a computer rather than a mobile device.*

About you

MM slash DD slash YYYY
Please enter a number from 15 to 105.
Address*
Drop files here or
Max. file size: 50 MB.

    Emergency contact information

    How did you hear about us?

    These questions help us better share the benefits of visual freedom and lens-free eyesight with people in our St. Louis community – people just like you.
    Which of the following do you use?*
    Where have you heard about Brinton Vision? Choose all that apply.*
    On which of these social media properties did you hear about Brinton Vision?*
    Where did you find us in your search?*
    Which one of our patients did you hear talking about us on the radio?*

    Your eye doctors

    So we can request records and better understand your eye history, please list your current eye doctor and any additional Missouri or Illinois eye doctors you have seen before.
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    Have you been tested for LASIK/vision correction surgery candidacy before?*

    Past LASIK candidacy

    What type of location was this at?*
    Who determined your candidacy?*
    Which LASIK/refractive surgeries were offered to you?*

    Past eye procedure details

    Which procedure did you have?*


    • MYOPIA. In 95% of cases LASIK/PRK is performed for myopia (nearsightedness). Prior to LASIK/PRK you could probably read up close just fine but could not see clearly in the distance without glasses. You may have noticed that when you put on your previous glasses objects looked smaller / minified and your eyes may have looked smaller in the mirror when looking through your glasses. Your far distance vision should have improved after laser eye surgery for MYOPIA.

    • HYPEROPIA. In 5% of cases LASIK/PRK is performed for farsightedness (hyperopia). Prior to LASIK/PRK you could probably see okay in the distance (though if you had very strong hyperopia even this may have been difficult). Your near vision was probably not good, or if you could see to read up close it strained your eyes. You may have noticed that when you put on your previous glasses objects looked bigger / more magnified and your eyes may have looked bigger in the mirror when looking through your glasses. Your near vision in particular should have improved after laser eye surgery for HYPEROPIA.

    Did you have LASIK/PRK to correct myopia or hyperopia?
    Were you completely satisfied after your procedure?*
    Patients who have had a previous LASIK, PRK, or RK procedure may qualify for either a laser enhancement procedure or custom lens replacement (CLR) procedure. To learn more, click here: brintonvision.com/custom-lens-replacement-st-louis

    Past eye history

    Select all vision conditions that apply*
    In the last twelve months, which best describes your use of prescription lenses?*
    Please enter a number from 0 to 95.
    Please enter a number from 0 to 95.

    My vision challenges -- contact lenses

    What type of contact lenses have you worn?*
    Which of the following risky contact lens habits have you practiced?*
    Which of the following complications have you experienced from contact lens wear?*

    About your current prescription glasses

    It is helpful in the treatment planning process to have your current glasses and test you in them. Do you have a pair of glasses that you can wear or bring to your BVOA consultation?*
    Approx. how old is the prescription for these glasses?*
    It's not fair that some people have to go through life with a prescription – our procedures level the playing field!

    Reading aids for patients 40+

    How do you read smaller print up close / within arm's reach?*

    Reading aids for patients 40+

    For which of these tasks do you require reading glasses?*
    Please enter a number from 0 to 75.
    Please enter a number from 0 to 70.
    Please enter a number from 1 to 100.
    Please enter a number from 0 to 17.
    You just left your house for work and discovered that you forgot your reading glasses*
    You just boarded a flight for a weeklong vacation and discovered that you forgot to pack reading glasses*
    Presbyopia ("old eye" in Greek) begins to occur in your forties or fifties when you lose the ability to read small print up close. Our procedures for presbyopia are designed to restore everyday reading vision so you can travel; take pleasure in a concert, theater, or sporting event; use your cell phone; read a restaurant menu; play sports; and enjoy other leisure activities without glasses. Our procedures do not replace magnification for professional or technical level near vision.*

    About your current contact lenses

    It is helpful in the treatment planning process to have your current contact lens prescription information. Can you bring your contact lens boxes or unopened lenses to your BVOA consultation?*
    Do you wear special contacts to help with your near vision?*
    With monovision or multifocal contacts, do you know which eye is set for better up-close reading vision?*
    Medical research has shown that wearing contact lenses is riskier for the eyes than established, safer alternatives such as wearing glasses or having LASIK/vision correction surgery.

    Dependency on glasses/contacts

    Please enter a number from 0 to 17.

    General medical health

    Select all health conditions that apply*

    We're sorry you are dealing with diabetes. Patients with diabetes need to wait until they have a stable hemoglobin A1c (HbA1c) and no medication changes for at least 90 days before they can be a candidate for LASIK/vision correction surgery. If you do not meet these criteria, email [email protected] and we will be happy to move your appointment to a later date.

    If you are pregnant, please email [email protected] and we will reschedule your Brinton Vision Ocular Analysis for the third month after your child's due date. Women planning to have LASIK/vision correction surgery should not attempt to become pregnant until they have finished their postoperative medicated eye drops, usually one week after vision correction surgery. For nursing mothers, the National Institutes of Health’s LactMed page says the medicated eye drops we prescribe (ofloxacin and PredForte) are low risk. To be conservative, however, we ask you to get a clearance note from your child's pediatrician or "pump and dump" for a week as most procedures require one week of medicated eye drops.

    We're sorry you are dealing with Marfan or Ehlers-Danlos syndrome. Patients diagnosed with Marfan or Ehlers-Danlos syndrome are not candidates for LASIK or surgical vision correction. We are happy to see you for health-of-eye exams and prescribe glasses (not contacts), however we will not recommend surgical eye correction. If you would like a refund of your exam fee, email [email protected].

    Please enter a number from 3 to 15.
    Do you have an autoimmune, collagen vascular, or immunodeficiency disease?*

    We're sorry you are dealing with an autoimmune or similar disease. Patients with these conditions need to wait until their condition is stable and have no medication changes for 90 days before they can be a candidate for LASIK/vision correction surgery. If you do not meet these criteria, email [email protected] and we will be happy to move your appointment to a later date.

    Choose one option*

    Medications and supplements

    Have you ever taken one of these medicines?*

    Patients currently taking Accutane (for acne) will need to wait 90 days after stopping the medication before they can be a candidate for LASIK/vision correction surgery. If you are currently taking Accutane, email [email protected] and we will be happy to move your appointment to a later date.

    If you have diabetes you will need to wait until you have a stable hemoglobin A1c (HbA1c) and no medication changes for at least 90 days before you can be a candidate for LASIK/vision correction surgery. If you do not meet these criteria, email [email protected] and we will be happy to move your appointment to a later date.

    If you have an autoimmune or similar disease, you will need to wait until your condition is stable with no medication changes for 90 days before you can be a candidate for LASIK/vision correction surgery. If you do not meet these criteria, email [email protected] and we will be happy to move your appointment to a later date.

    Do you use any of the following that can cause dry eye?*

    Allergies

    Do you have any allergies to medications?
    Are you allergic to any of the following?*

    Your personality

    On a scale from 1 (easy going) to 5 (perfectionist), how would you describe your personality?*
    We take pride in meeting and exceeding our patients’ vision goals, even for those with a perfectionistic personality! At the same time, it’s important to have reasonable expectations about what modern laser and lens implant eye surgery can do and what it can’t do. Please take time to share your vision goals and expectations with your doctor at your BVOA.*

    Lifestyle

    Check common reasons for wanting to have LASIK that apply to you*
    Is either hunting or target shooting important to you?
    For how long have you considered improving your eyesight with LASIK?*
    If our doctor determines that you are a candidate for LASIK, how soon are you wanting treatment?*

    Paying for your LASIK / vision correction procedure

    We believe that financial considerations should not be an obstacle to obtaining the clear vision you deserve! Brinton Vision accepts many forms of payment and offers in-house flexible payment options to help make your eye correction procedure fit most budgets. Please note our policy that pre-payment in full is required at the time a procedure or exam in our office is scheduled.
    Should you be a candidate for vision correction, how do you plan to pay for your care? Check all that apply.
    95% of our patients qualify for flexible payment options. If you have placed a lock or freeze on your credit, remember to have this temporarily lifted prior to arrival.

    Upload any prescriptions or chart notes from previous eye doctor visits


    (optional) Providing a photograph or scan of the following can be helpful to our team.
    - previous eye records
    - any eye prescriptions
    - picture of contact lens boxes or foils showing numbers
    - picture of your pets (our staff love animals!)
    Drop files here or
    Max. file size: 50 MB.

      Questions for Brinton Vision doctor

      Do you have specific medical questions that you would like our doctors to address during your consultation?*
      Is this your first time visiting Brinton Vision as a patient or guest?*

      Disclosures

      Patients are required to check in with our receptionist fifteen minutes prior to their appointment time. Late arrivals will be asked to book a new appointment. You are required to show a driver's license or government-issued photo ID for us to scan upon arrival at your first appointment.*
      At our office, we'll use dilating eye drops to enlarge your pupils for a better view inside your eye. These drops may blur your vision and make bright lights uncomfortable, so bring sunglasses for after your exam. Most patients can drive afterward, but if you're unsure how you’ll react, especially if you have poor eyesight or a long drive, consider bringing someone to drive you home.*
      We recommend a yearly dilated eye exam with a qualified eye doctor to maintain optimal vision and prevent eye disease. By becoming our patient, you agree to follow this advice. Annual exams are not included in surgery fees, as yearly eye exams are advised for all patients, whether you wear glasses, contacts, or have corrective eye surgery.*
      For internal training purposes only, Brinton Vision may record, with audiovisual equipment, your clinical exam. This is an important part of our dedication to provide a patient experience focused on you. If you are uncomfortable with this you may opt out here.*
      We routinely provide medical updates to your doctors and healthcare providers to ensure the highest quality of care. Our doctors, medical technicians, and staff may communicate with you and with other healthcare providers by regular email, text, phone, postal mail, or voicemail. Phone calls may be recorded for quality assurance purposes. Reply STOP to opt-out of text messages. Messaging frequency may vary and data rates apply. Our privacy policy can be found at brintonvision.com/legal-statements. Private information should be shared with our doctors in person only.*
      It is helpful for our staff to review your past eye history prior to your initial visit. Our standard practice is to request this from any eye doctor(s) in our area that you listed. If you want to opt out of this and not have us consider records from a particular doctor, you may omit this doctor’s name on this intake form. For a period of one year from the date of my signature below, I authorize and request any optometrist, ophthalmologist, or eye care facility that has provided treatment or service to me or on my behalf to disclose and release my medical records by regular email, text message, or postal mail. My medical records include, but are not limited to: progress notes, clinical charts, treatment plans/reviews, test results, photographs, medical assessments, or records received by other medical providers. I understand that I have the right at any time to revoke this authorization, except to the extent information has been released in reliance upon this authorization. I understand that in order to revoke this authorization, I must do so in writing to Brinton Vision. I understand that I may request a copy of this authorization and that a photocopy is as valid as the original copy. I understand that authorization for disclosure of my health information is voluntary and that I may refuse to grant this authorization for any previous doctor/healthcare provider by removing the identity of the doctor/healthcare provider above. I understand that my electronic signature constitutes my agreement and authorization for release of records as described here.*
      Clear Signature