Toronto's Laser Eye Surgery & Vision Correction Centre

Call today ~ 866.415.2210

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	Call today and book a free consultation at 1 866 415 2210

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If you want expert care, personal attention, and great value, contact Yonge Eglinton Laser Eye + Cosmetic Centre.

Yonge- Eglinton Laser Eye + Cosmetic Centre

2345 Yonge Street, Suite 212, Toronto, Ontario, M4P-2E5
Tel: (866)415.2210, Fax: 416 545 0049
Email: info@yelc.com

Name* :

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BRIEF HISTORY AND QUESTIONNAIRE

1. Which is the best way to contact you?

2. What radio station(s) do you listen to?

3. Which newspaper(s) do you read regularly?

4. How did you hear about us?
	Radio	Newsletter	Billboard	Health Fair
	TV	Newspaper	Direct Mail	Internet
	Friend, Who?		Other

5. My main visual problem (check all that apply):	6.My current prescription is for (check all that apply)
Fine Print	Myopia or nearsightedness
Near Vision	Hyperopia or farsightedness
Intermediate/Computer	Astigmatism
Distant vision	Presbyopia
Night Driving	Unsure at this time

7. Do you currently wear (check all that apply):
Glasses for Distance	Extended Wear Contact Lenses
Progressive Glasses	Toric Contact Lenses
Bifocal or reading glasses	Monovision Contact Lenses
1-2 week Disposable Contact Lenses	RGP/Hard Contact Lenses
Monthly Disposable Contact Lenses	Contact lenses last worn
Specs: OD OS

8a. Do you have a history of the following (check all that apply):
Kerataconus	Glaucoma
Diabetes	Keloid Former
High Blood Pressure	Past Eye Conditions
Thyroid Condition	Former Surgeries
Pregnant/Nursing	Other not listed above

8b. Allergies to medications (please list):

9. Current Medications being taken at present time:

9b. When was your last eye exam?

Yes

10. Has anyone ever told you that you would be a good candidate for the Lasik procedure?

11. Do you know any friends or family members who have had the Lasik procedure?

12. Is this your first vision correction consultation?

13. Do your glasses or contacts interfere with your recreational activities?

14. If you could function throughout your day without dependence on contacts or glasses, would you consider the procedure a success?

15. Did you know that LASIK is a two-step procedure?

16. Are you interested in learning about our various financing programs?

17. What is it about your glasses or contacts that currently prevent you from enjoying everyday living?

18. What do you hope to achieve by having the LASIK procedure that glasses and contacts currently do not provide you with?

19. How long have you been considering the LASIK procedure?

20. Do you have any fears regarding vision correction?

21. Is there anything preventing you from proceeding with the LASIK procedure prior to your visit other than financial arrangements?

22. When do you plan on having LASIK?

Whether you visit our Toronto practice for laser eye surgery, laser hair removal, or BOTOX® Cosmetic injections, you'll be in good hands. That's because every member of the Yonge Eglinton team is skilled, experienced, and attentive to detail.

And when it comes to cost, you can rest assured that our Toronto laser eye surgery practice will offer you the best value for your money.

So if you live in or near Toronto are would like to find out more about laser eye surgery, laser hair removal, or BOTOX® Cosmetic, we invite you to schedule a consultation at Yonge Eglinton Laser Eye + Cosmetic Centre. For your convenience, you can contact us by filling out and submitting the form below. We look forward to hearing from you.


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