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WHICH TYPE OF CONSULTATION CAN WE HELP YOU WITH?

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Hello! This information will not only help us start thinking about your visual needs and what procedure might be best for your unique eyes, but it also will save you time so you don’t need to fill out any paperwork on the day of your consultation. This account also gives you access to all of our VIP options like online or in-app scheduling and personalized educational material.

FIRST NAME*

MIDDLE NAME

LAST NAME*

UPLOAD PHOTO Photo Preview

(adding a clear photo
of your face allows us
to recognize you when
we first meet for the
ultimate VIP experience!)

WHAT WOULD YOU
LIKE US TO CALL YOU?

What is your Date of Birth*

If you could wake up tomorrow
and see without glasses or contacts,
what's the first thing you'd do?

We’re so excited to meet you!

Please complete this form to the best of your knowledge and save time when you arrive at our practice. This replaces any paperwork we need and also allows you to create a Bimini Vision VIP account. This account allows you to easily re-schedule appointments, access exclusive app features, and easily message us.

Email Address*

Preferred Phone*

Alternate Phone

Goals

I’m most interested in

I currently wear

Soft contact lenses
Hard contact lenses
Glasses
Readers
None of these

The approximate prescription of my RIGHT eye is

The approximate prescription of my LEFT eye is

Known eye conditions

Glaucoma
Cornea injury / Scar
Keratoconus
Cataracts
Herpes eye disease
History of eye surgery
Lazy eye
None of these

Known medical conditions

Heart disease
Lung disease
Kidney disease
Diabetes
Neurologic disease
Hepatitis
Fibromyalgia / Rheumatoid Arthritis
Hashimoto / Grave’s
Blood clots
Amiodarone / Accutane use
Hyperthyroidism
Hypothyroidism
High blood pressure
Cancer
HIV / AIDS
Pregnant / Nursing
Autoimmune
None of these

Have you experienced recent

Racing pulse
High blood pressure
Shortness of breath
Anxiety / Depression
Seasonal allergies
Joint pain / arthritis
Acid reflux
None of these

Laser weight limits

Prescription Medications

Food or drug allergies

Reaction to anesthesia?

Social history

I don’t smoke or drink
I smoke cigarettes or cigars
I drink alcohol

Recreational drugs

Other medical conditions

Family history

Glaucoma
Keratoconus
Retinal Detachment
Macular Degeneration
None of these

Surgeries in the past year

Photo ID

How did you hear about us?

Additional contacts

Other preferences

Preferred Contact Method*

App Notifications
Email
Text Call

TERMS

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Its Great to meet you!

Please fill out this form to the best of your knowledge.

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WELCOME!

to BIMINI VISION

LASIK, Laser, and Refractive Surgery

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