surgeo-and-safari

 

 

 

STEP BY STEP GUIDE

CLIENT COMMENTS

PUBLICITY

 

"I now realize it is this person who can make or break the whole adventure, and for this reason highly recommend the place to my friends. I have several who are really keen to go."

With much love, Jeri

Informed Choice - Questions you need to ask yourself

  • Are you able to use extended forms of communication like Email, Telephone and communicate with Past clients?
  • Have you asked questions, raised your concerns and fears?
  • How do you feel about how the Surgeon has addressed your questions?
  • Has your communication been open and honest?
  • Are you sure that you have realistic expectations?
  • Have you been made aware of the benefits and risks involved?

 

Name
Surname
Date of Birth
Address
Country
Telephone
Fax
Email Address
Occupation
Hobbies, Interests and sports
Name of Surgeon
When did you intend to travel to South Africa?
Hyperopia (Far Sighted)
Yes No
Myopia (Short Sightedness)
Yes No
Astigmatism
Yes No
Keratoconus (Irregular astigmatism)
Yes No
Do you need reading glasses?
Yes No
Blindness
Yes No
Any other eye disease? Please specify
Contact Lenses
Yes No
Type - Hard or Soft
Strength Right Eye
Strength Left Eye
Previous Eye Surgery? Please specify below
Yes No
Procedure
Current Eye Medication
Recent Optometrist Report
Refraction Right Eye
Refraction Left Eye
Stable refraction > 2 years
General History
Age
Allergies
Hypertension
Diabetes
Malignancies
Current Non Ophthalmic Medication
Have you had your Cornea tested for suitability to Excimer laser surgery
Yes No
If so, please give summary of results
Please state the recommended procedure if applicable
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW

I have read the terms and conditions above:
Yes No
Please click on the send button or print this page
and then fax to : +27 11 706 5582
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Please be assured that all electronic data received is treated with the strictest confidentiality.

Any medical or surgical advice provided through this web site service, even if intended to be accurate to the best of our knowledge, should be discussed with the surgeon before embarking on any treatment, medication or therapy.

Thank you for taking the time to complete this profile.



 

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