Lens Replacement
PLEASE NOTE: It is necessary to provide us with all medication you use for all health problems in order to correctly indicate you to a surgery. In case if false, not complete information or concealed medical history is provided your treatment might be cancelled with no financial refund.
Name and Surname:
*
Country:
United Kingdom
Ireland
Aruba
Afghanistan
Angola
Albania
Andorra
United Arab Emirates
Argentina
Armenia
American Samoa
Antigua and Barbuda
Australia
Austria
Azerbaijan
Burundi
Belgium
Benin
Burkina Faso
Bangladesh
Bulgaria
Bahrain
Bahamas
Bosnia and Herzegovina
Belarus
Belize
Bermuda
Bolivia, Plurinational State of
Brazil
Barbados
Brunei Darussalam
Bhutan
Botswana
Central African Republic
Canada
Switzerland
Chile
China
Côte d’Ivoire
Cameroon
Congo, the Democratic Republic of the
Congo
Cook Islands
Colombia
Comoros
Cape Verde
Costa Rica
Cuba
Cayman Islands
Cyprus
Czech Republic
Germany
Djibouti
Dominica
Denmark
Dominican Republic
Algeria
Ecuador
Egypt
Eritrea
Spain
Estonia
Ethiopia
Finland
Fiji
France
Micronesia, Federated States of
Gabon
Georgia
Ghana
Guinea
Gambia
Guinea-Bissau
Equatorial Guinea
Greece
Grenada
Guatemala
Guam
Guyana
Hong Kong
Honduras
Croatia
Haiti
Hungary
Indonesia
India
Iran, Islamic Republic of
Iraq
Iceland
Israel
Italy
Jamaica
Jordan
Japan
Kazakhstan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Saint Kitts and Nevis
Korea, Republic of
Kuwait
Lao People’s Democratic Republic
Lebanon
Liberia
Libya
Saint Lucia
Liechtenstein
Sri Lanka
Lesotho
Lithuania
Luxembourg
Latvia
Morocco
Monaco
Moldova, Republic of
Madagascar
Maldives
Mexico
Marshall Islands
Macedonia, the former Yugoslav Republic of
Mali
Malta
Myanmar
Montenegro
Mongolia
Mozambique
Mauritania
Mauritius
Malawi
Malaysia
Namibia
Niger
Nigeria
Nicaragua
Netherlands
Norway
Nepal
Nauru
New Zealand
Oman
Pakistan
Panama
Peru
Philippines
Palau
Papua New Guinea
Poland
Puerto Rico
Korea, Democratic People’s Republil Salvador
San Marino
Somalia
Serbia
Sao Tome and Principe
Suriname
Slovakia
Slovenia
Sweden
Swaziland
Seychelles
Syrian Arab Republic
Chad
Togo
Thailand
Tajikistan
Turkmenistan
Timor-Leste
Tonga
Trinidad and Tobago
Tunisia
Turkey
Tuvalu
Taiwan, Province of China
Tanzania, United Republic of
Uganda
Ukraine
Uruguay
United States
Uzbekistan
Saint Vincent and the Grenadines
Venezuela, Bolivarian Republic of
Virgin Islands, U.S.
Viet Nam
Vanuatu
Samoa
Yemen
South Africa
Zambia
Zimbabwe
Phone:
E-mail:
*
Considered date for the treatment:
*
Date of Birth:
*
Weight:
*
Height:
*
Do you wear glasses for distance?
Yes
No
Do you wear glasses for near vision/ reading glasses?
Yes
No
Do you know your prescription - for both long and short distance?
1. Are you fit and well?
Yes
No
2. Have you had any eye operations in the past?
Yes
No
3. Do you use any eye drops?
Yes
No
4. Do you regularly attend hospital for your eyes?
Yes
No
5. Do you suffer from any auto immune disease?
Yes
No
6. Have you had any operation in the past? (heart, kidney etc.)
Yes
No
7. Do you suffer from a lazy eye (amblyopia)?
Yes
No
8. Have you ever had any eye injury?
Yes
No
9. Do you suffer from heart disease, or have you ever had problems with your heart?
Yes
No
10. Are you being treated for high blood pressure?
Yes
No
11. Is anyone of your relatives being treated for glaucoma?
Yes
No
12. Do you suffer from any respiratory disorder?
Yes
No
13. Do you receive treatment for diabetes?
Yes
No
14. Are you being treated for a nervous disease?
Yes
No
15. Are you at present suffering from a cold or influenza?
Yes
No
16. Have you ever been admitted to hospital or been treated / taken medication for a mental illness?
Yes
No
Drug Reactions/Allergies:
Please list below any known drug allergies or reactions, or sensitivities.
Prescription Medications:
Please list all prescription medications you currently take:
Non-Prescription Medications / Dietary Supplements / Vitamins / Herbs / Minerals:
If you currently take items in this category, please list below.
Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray)
Please indicate your current status regarding these items below:
Do you SMOKE or use TOBACCO/NICOTINE PRODUCTS?
Yes
I am a NON SMOKER and do not use nicotine products.
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