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33%
First and last name
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Date of birth
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Appointment are you requesting to cancel
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New consultation for surgical procedure.
Health of eye exam (already had procedure performed)
Punctal plugs
Scheduled surgical procedure
Which Surgery?
SBK LASIK
EVO ICL
Custom Lens Replacement (CLR)
PRK
SMILE
KAMRA
LRI
YAG
Date of appointment
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MM slash DD slash YYYY
What best describes your reasons for cancelling?
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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
Returning to my regular eye doctor
Fear or anxiety
Life changes (moving, pregnant, job loss, etc.)
Other
What best describes your reasons for cancelling surgery?
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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
Fear or anxiety
Life changes (moving, pregnant, job loss, etc.)
Other
Please share why — your feedback is very important to us as we are continuously working to improve the quality of our patient care.
When are you planning to reschedule?
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In the next three months
Within the next year
I do not know yet
When are you planning to reschedule you surgery?
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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??
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Financial reasons
Fear/Anxiety
Prefer not to say
That is understandable, most people have some level of fear or anxiety when it comes to their eyes. Please take the time to read this article before proceeding.
5 Ways to Not Be Nervous, Scared or Have Anxiety About Your LASIK Procedure
I have read the article.
*
I would like to speak to a team member.
I still want to cancel
Are you planning to proceed with a local surgeon practice or national corporate-owned chain?
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Local surgeon practice
National corporate-owned chain
Prefer not to say
We understand, have you made an appointment with them yet?
Yes
No
What is the best phone number to reach you at?
What is the best email to reach you at?
Your BVOA Reservation Fee is good for one year, would you like to
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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?
MM slash DD slash YYYY
Which of the four corporate-owned national chains have you selected?
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Clarkson
Lasik Plus
Lasik Vision Institute / LVI
TLC Laser Eye Centers
Please select which payment options you used
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Cash
Check
Credit card
Flexible payment plan - Ally interest free for 24 months
Flexible payment plan - Ally, 60-month extended payments
Flexible payment plan - Alphaeon, zero down, 0% interest for 24 months
Flexible payment plan - Alphaeon, 60-month extended payments
Flexible payment plan - CareCredit
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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Yes