Request an Appointment

If you would like to be contacted to book a pre-operative assessment or to schedule tentative plans for surgery, please complete and submit the information below.

Today's Date:(mm/dd/yy)
Name:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
I prefer to be contacted at:	Home Work
How did you hear about the Casey Vision Correction Center?
Radio	Newspaper
Internet	Eye Doctor
Reputation
Other:
Have you attended one of our seminars?	Yes No
Occupation or type of work
Have you ever been a patient at OHSU?	Yes No
Recent prescription for your glasses or contact lenses: (enter all numbers from your prescription - separated by spaces)
Right eye (OD):
Left eye (OS):
If you are a contact lens wearer, what type do you wear?
Hard Soft Gas-Permeable
How many years have you been wearing contact lenses?
Have you ever been diagnosed wth an eye disease?	Yes No
If yes, please specify
List any known health problems:
List any medications you are taking:
List any allergies to medication:
Are you pregnant or nursing?	Yes No
Who is your optometrist?
Who is your ophthalmologist?
Please feel free to write any comments or questions: