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Yonge Eglinton Laser Eye +Cosmetic Centre

2345 Yonge Street, Suite 212
Toronto, Ontario, M4P 2E5

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Ph. 877-950-1414
Fx. 416-545-0049

Recognized for Laser Eye surgery by the Toronto Sun View Our Photo Gallery

Corrective Vision Procedures with Dr. David Rootman

Dr. David Rootman and the other ophthalmologists at Yonge Eglinton Laser Eye & Cosmetic Centre perform many corrective vision procedures including, IntraLase® LASIK, PRK, LASIK, LASEK, cataract surgery with ReSTOR® and ReZoom™ lenses, and corneal transplants using DLEK and DSEK.

The first step for a consultation with Dr. Rootman or one of our other eye surgeons is to complete the patient consultation form below. This form will provide our team with background information that will allow us to better meet your needs.

After submitting the form you will be contacted by a member of the staff at Yonge Eglinton Laser Eye & Cosmetic Centre.

  * indicates a required field
Last Name*:
First Name*:
M.I.*:
Street Address*:
Apartment/Unit #:
City*:
Province/State*:
Postal Code/Zip Code*:
Home Phone*:
Business Phone:
Cell Phone:
E-mail Address*:
Gender Male Female
Date of Birth*: (mm/dd/yyyy)
Age*:
Brief History and Questionnaire
Which is the best way to contact you
What radio station(s) do you listen to?
Which newspaper(s) do you read regularly?
How did you hear about us?
(Please specify)
Z103.5
FLOW 93.5
97.3 EZRock
Newsletter
Billboard
Health Fair
TV
Newspaper
Internet
Direct mail
Friend
Name:
Other
Please specify:
My main visual problem
(check all that apply) 		Fine print
Near vision
Intermediate/Computer
Distant vision
Night driving
My current prescription is for
(check all that apply) 		Myopia (nearsightedness)
Hyperopia (farsightedness)
Astigmatism
Presbyopia
Unsure at this time
Do you currently wear
(check all that apply) 		Glasses for distance
Progressive glasses
Bifocal or reading glasses
1-2 week disposable contact lenses
Monthly disposable contact lenses
Extended wear contact lenses
Toric contact lenses
Monovision contact lenses
RGP/hard contact lenses
Specs:
OD:
OS:
Contact lenses last worn:
Do you have a history
of the following
(check all that apply) 		Keratoconus
Diabetes
High blood pressure
Thyroid condition
Pregnant/nursing
Glaucoma
Keloid former
Past eye conditions
Former surgeries
Other not listed above
Allergies to medications
(please list)
Medications being taken at present time:
When was your last eye exam?
Has anyone ever told you that you would be a good candidate for the LASIK procedure? No Yes
Do you know any friends or family members who have had the LASIK procedure? No Yes
Is this your first vision correction consultation? No Yes
Do your glasses or contacts interfere with your recreational activities? No Yes
If you could function throughout your day without dependence on contacts or glasses, would you consider the procedure a success? No Yes
Did you know that LASIK is a two-step procedure? No Yes
Are you interested in learning about our various financing programs? No Yes
What is it about your glasses or contacts that currently prevent you from enjoying everyday living?
What do you hope to achieve by having the LASIK procedure that glasses and contacts currently do not provide you with?
How long have you been considering the LASIK procedure?
Do you have any fears regarding vision correction?
Is there anything preventing you from proceeding with the LASIK procedure prior to your visit other than financial arrangements?
When do you plan on having LASIK?