Appointment-Eye Laser Consulting

If you would like to make an appointment with our office or visit us for a complimentary consultation for LASIK, please fill out and submit the Confidential Medical History form on this website. You may also print this page and fax it to us at (520) 797-2235.The form is confidential.

Please provide the following CONFIDENTIAL medical history:

First Name
Last Name
Address
City
State/Province
Zip/Postal code
Country
Phone
FAX
E-mail

Appointment Information:

What do you like to be called?

Today's Date:

What days of the week are best for you?

What times of day are best?

Please answer the following important questions about your health:

How can we help you during your visit to our office?

Have you had recent major surgery?

Type:	Date:
Type:	Date:

List ALL present medications (over-the-counter and prescription):

List ALL eye drops:

Who is your primary Doctor?

Who referred you to our office?

Allergic to any medications?

Do You Smoke?
Yes	No
Do You Drink?
Yes	No
Do You Use Drugs?
Yes	No
If yes, explain:

Have you had eye surgery for:
Yes	No
		Cataracts
		Crossed Eyes
		Glaucoma
		Retinal Detachment
		Nearsightedness/Astigmatism
		Do you wear glasses?
		Do you wear contacts?
Family History:
Yes	No
		Heart Disease
		Diabetes
		High Blood Pressure
		Glaucoma
		Cataracts
		Retinal Detachment

Comments:

Change the way you SEE...and change your LIFE! Robert M. Kershner, MD, FACS is one of the most experienced refractive eye specialists in the world having helped thousands of your friends and neighbors to see more clearly. Eye Laser Consulting-Boston, MAssachusetts USA Call or Contact us through this site NOW!

*Individual results may vary. Persons over the age of forty are more likely to require glasses for reading. Sunglasses may be necessary when out of doors. As with all surgical procedures, there is no assurance or guarantee as to the outcome of the procedure.

This website is intended for educational purposes only. It is not a substitute for medical advice from a physician. Use of this site constitutes an agreement with the user that releases Eye Laser Consulting and Robert M. Kershner, MD, MS, FACS from any and all liability.

Eye Laser Center
Robert M. Kershner, M.D., P.C., F.A.C.S.
Boston, Massachusetts USA

SET YOUR SIGHT ON US...AND SET YOURSELF FREE!

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Robert M. Kershner, MD, FACS, PC
Copyright © 1998-2004. All servicemarks, trademarks and copy herein are registered property of Robert M. Kershner, MD, PC. All rights reserved. Version 01012004