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Thank you for taking the time to fill out our patient intake form. The Brinton Vision Ocular Analysis is a process focused on YOU, and this intake form represents the first step in that process. As we get to know each other better you will find that our Brinton Vision team is caring, detailed, and thorough as we work alongside you to help you meet your vision goals. Because of this, our form asks you to answer a number of very specific questions about how you use your eyes – we appreciate your providing a complete response to each question. Our patients tell us that this form takes about twenty (20) minutes to complete. Thank you in advance!*

About you

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

Emergency contact information

A great deal of information about your overall wellness and ocular health is shared during your Brinton Vision Ocular Analysis. Our patients often mention that they appreciated having a friend or family member participate to provide them with a second set of eyes and ears.

Patients are welcome to bring one guest with them to the office for their initial consultation.

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.
Where have you heard about Brinton Vision? Choose all that apply.*
Who in the doctor’s office told you about Brinton Vision?
Which search engine did you use?*
Where did you find us in your Google search?*
On which of these social media properties did you hear about Brinton Vision?*
Which one of our patients did you hear talking about us on the radio?*
Which of the following do you use?*

Your eye doctors

Please list your current eye doctor and any eye doctor you have seen in the past five years.
MM slash DD slash YYYY
Name of Referring Eye Doctor*

Past LASIK candidacy

Have you ever been told that you are a candidate for LASIK or vision correction surgery?*
Which modern laser/lens eye correction procedures were offered to you?*

Past eye procedure details

Have you previously had LASIK or any other vision correction procedure?*
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?*
MM slash DD slash YYYY
Were you completely satisfied after your procedure?*
Are you looking to have laser enhancement of your vision or other correction?*
Patients who have had a previous LASIK, PRK, or RK procedure may qualify for either a laser enhancement procedure or refractive lens exchange (RLE) procedure. To learn more, click here.

Past eye history

Select all vision conditions that apply*
How is/was the keratoconus treated?*
How is/was the glaucoma treated?*

My vision challenges

For patients age 15-39, which vision problem do you have?*
For patients age 40 and up, which vision problem do you have?*
Which best describes the prescription lenses you use?*

Near reading and computer work

Please enter a number from 8 to 24.
Do you use a computer on a daily basis?*
Do you use a laptop, desktop, or both?*
Please enter a number from 1 to 7.
Please enter a number from 0.5 to 18.
How many computer monitors do you use at a time?*
Approximately how far away is your monitor?*
Max. file size: 50 MB.
Max. file size: 50 MB.

Visual aids for poor eyesight

Please enter a number from 1 to 105.
How old is your glasses prescription?*
Please enter a number from 1 to 105.
Can you wear or bring these glasses to your BVOA appointment?*
It is helpful in the treatment planning process to have your current glasses and test you in them.
How do you read print up close / within arm's reach?*
Presbyopia occurs in your forties or fifties when you lose the ability to read up close. While our procedures are designed to restore everyday reading vision – so you can see your watch, dashboard, cell phone, and restaurant menu again – they are are not designed to replace magnification for professional level near vision. Some patients may still use a pair of readers for magnification with some near vision tasks, particularly in a professional setting or when fine print or dim lighting are involved. Talk to your Brinton Vision doctor about your near vision needs, and remember that surgical corrections over age 40 involve give and take or trade-offs, even if your procedure allows you to see everything you need to.*
It's not fair that some people have to go through life with a prescription – our procedures level the playing field.

About your glasses

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*

About your contact lenses

How old is your contacts prescription?*
Do you wear special contacts to help with your near vision?
Can you bring your contact lens boxes or unopened lenses to your BVOA appointment?*
It is helpful in the treatment planning process to have your current contact lens prescription information.
Max. file size: 50 MB.

Contact lens habits, risks, and complications

What type of contact lenses do you wear?*
Where possible, we recommend being out of contact lenses for 3 days; being out for 7 or more days is ideal.
Which of the following risky contact lens habits have you practiced?*
Which of the following complications have you experienced from contact lens wear?*

General medical health

MM slash DD slash YYYY
Select all health conditions that apply*
If you are pregnant, please let us know and we will reschedule your Brinton Vision Ocular Analysis for one month after your child's due date. Women planning to have LASIK or vision correction surgery should not attempt to become pregnant until they have concluded their postoperative medicated eye drops following their vision correction procedure. Nursing mothers should "pump and dump" while taking their prescribed eye procedure medications. Most procedures require one week of medicated eye drops.*
Would you be able to obtain written clearance from your primary care medical provider stating that your condition is well-managed and stable for three months prior to your eye procedure?*

Medications and supplements

Have you ever taken the acne medication Accutane/isotretinoin or an alpha-blocker used to treat urinary symptoms or enlarged prostate such as Flomax, Hytrin, Cardura, or Uroxatra?*
Do you use any of the following that can cause dry eye?*

Allergies

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*

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 budget. Please note our policy that payment in full is required at the time any procedure or exam in our office is reserved/booked. Insurance does not cover laser vision correction procedures because they are not considered a medical necessity.
Should you be a candidate for vision correction, how do you plan to pay for your care? Check all that apply.
In our office, in addition to finding out if you are a candidate for LASIK/vision correction surgery, you can also find out if you qualify for flexible payment options. Approximately 95% of our patients qualify. If you have placed a lock or freeze on your credit, remember to have this temporarily lifted prior to arrival. Alternatively, patients may obtain pre-approval for financing, if desired, by clicking one of the following links:

- Ally - "soft" check with no effect on credit score

- Alphaeon Credit - "soft" check with no effect on credit score

For all appointments at Brinton Vision, we take pre-payment in full at the time of booking. If you are booking your surgery on a payment plan, your first payment will usually be due within 4-6 weeks. This means that if your surgery date is more than 4-6 weeks out, your first payment may be due before your surgery date.

Upload any prescriptions or chart notes from previous eye doctor visits


Providing a photograph or scan of the following can be helpful to our team. (optional)
- previous eye records
- any eye prescriptions
- picture of contact lens boxes showing numbers

Max. file size: 50 MB.

Questions for Brinton Vision doctor

Disclosures

For internal training purposes only, Brinton Vision may record, with audiovisual equipment, your preoperative 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.*
From time to time we will be filming in the clinic for use in various media outlets and platforms. I authorize Brinton Vision to use my name, image, voice, and likeness in its media publications and platforms.*
All patients are required to arrive at our office fifteen minutes prior to your appointment time to check in. Late arrivals will be asked to book a new appointment. You are required to show a driver license or government-issued photo ID for us to scan upon arrival at your first appointment. Late arrivals or patients without a government-issued ID will will be asked to book a new appointment.*
We encourage all patients to have a yearly dilated eye exam with a qualified eye doctor to ensure the best quality of vision and prevent eye disease. By becoming our patient you agree to follow this recommendation. Our doctors and medical technicians may communicate with you via phone, text, email, or voicemail. We also routinely provide medical updates to your other care providers to ensure the highest quality of care.*
We routinely provide medical updates to your doctors and care providers to ensure the highest quality of care. It is often 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 list above. If you want to opt out of this and not have us consider records from a particular doctor, please 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/release my medical records including, but 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 protected health information is voluntary and that I may refuse to grant this authorization for any previous doctor by removing the identity of the doctor above. I understand that my electronic signature constitutes my agreement and authorization for release of records as described here."