new patient forms

First Name *

Last Name *

Height *

Weight *

Where did you first hear about CS LASIK Institute? *

Have you ever seen CS LASIK Institute on Facebook or Instagram? *

Yes

Based on WHERE you first heard about us, please rate your first impression of CS LASIK Institute. 5=best 1=worst *

Was scheduling your consultation easy and convenient? *

Yes

Have you been screened for vision correction before? *

Yes

When did you start your laser vision correction research? *

5-10 years ago

1-5 years ago

less than 1 year ago

What has held you back from laser vision correction? *

How are you feeling about your consultation? *

Fearless & Pumped "Let's do this!"

Hopeful but Nervous "I hope this goes well."

Stressed "Am I candidate?"

Excited "Oh happy day, finally!"

Anxious "Is it over yet?"

What favorite activity are you most excited about doing lens-free? *

HIPPA Acknowledgement and Consent Form

HIPAA Acknowledgement and Consent Form I understand that, under the Health Insur-ance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: *Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. *Obtain payment from designated third-party payers. *Conduct normal health care operations such as quality assessments or evaluations, and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (copy availa-ble in office). I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that CS LASIK Institute has the right to change its Notice of Privacy Practices from time to time and that I may contact CS LASIK Institute at any time at the address below to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that CS LASIK Institute restrict how my pri-vate information is used or disclosed to carry out treatment, payment or health care operations. I also understand CS LASIK Institute is not required to agree to my request-ed restrictions, but if CS LASIK Institute does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent. You may refuse to sign this consent. Please type your name below to sign consent.

If you are human, leave this field blank.

Lifestyle Vision Questionnaire

HIPPA Acknowledgement and Consent Form