To schedule a free Refractive Surgery consultation, please use the contact form below. The more details your can give us, the better. You can also fill the self-referral form at the bottom of the page, this will make your appointment happens much faster.

Please follow the link to schedule an appointment. Medeo Online Appointment Scheduling

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Referral Form (For First Timers or For Updates)

Please fill out the form and send to us

Personal Details

Name *
Medicare Number
Date of Birth (MM/DD/YYYY) *
ADDRESS *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone Home and Mobile if Available *
Email *

Referral Details

Optometrist
Family Doctor
Who Reffered You *
Referred by Family DoctorReferred by the OptometristSelf Referral or by Family MemberReferred by Emergency DoctorReferral by other doctors
Uregency of Referral *
EmergencyUrgentSemi UrgentNot Urgent
Main complaint or reason for the consultation *
Blurry visionItchy, burning, and dry eyeGlaucoma: suspect of family historyRetina problemsFloaters and flashesI want to get rid of my glasses (refractive surgery)I have cataracts and want them removedI need BotoxI have a skin tag or a cyst or something that I want removedI want my eyes checkedOthers (details in the message field)
Other Complaints:

Health Details

List of medications, doses and why you take them?
Current Medical Problems
DiabetesHypertensionCholesterolCardiac ProblemsLung ProblemsStomachProstateCancersBone and JointAnxiety or DepressionStrokesHearing ImpairmentOthers (Explain in the medication field)
Other health problems that you know that you have

Eye Details

Eye Problems
CataractLens ImplantsGlaucomaPutting Glaucoma DropsRetina ProblemsDiabetic RetinopathyIntraocular InjectionsHad Lasers Eye SurgeriesDry eyesOthers (Explain below)
Eye problems that you know you have
Glasses or Contacts prescription if known
Refractive surgery assessment (check all that apply)
I wear contactsI did wear contacts but stoppedI am interested in getting rid of my glassesI have tried monovision with contact lensesI am prepared to see some halos around lights at night, if I could have good distance vision during the day and good near vision for reading, both without glassesI do you spend a lot of time in bright sunlightI do wear sunglassesI have had a previous assessment to have Laser Vision CorrectionI read without glassesI drive without glasses

Other Details

Message and other notes

Visit Preparation

Instructions for the Visit (Checklist) *
Please check off each item to be able to submit the formPlease bring a driver as your pupils might need to be dilatedBring your health cardBring a list of medicationsBring the lens implant cards if you had already a surgery doneIf you had previous Laser Vision Correction, please bring any details that you can about the surgery or at least your prescription from before the surgeryDo not wear contacts to the visit. If you are coming for a cataracts assessment, you have to be out of contacts for 72hrs. The longer, the better. RGBs needs weeks without the Contacts for the cornea to go back to normal.Some testing methods are not covered by Medicare, might require out of pocket payment.If your Visit/communication is of an emergency nature, please go to the ER at Cornwall Hospital, they know how to reach us in these situations.

Booking Preferences (Will try to Accommodate)

Days of the week you PREFER to be booked on?
MondayTuesdayWednesdayThursdayFridayNo difference, any day is okay
Days to AVOID being booked on
MondayTuesdayWednesdayThursdayFriday
Time of the Day You prefer to be booked around?
Early Morning (we start at 7AM)MorningNoonAfternoonLatest Possible (After work)No Difference, Any time is okay
Instructions We will try to accommodate these days and times preferences as much as we can. Please accept our apologies if we can't due to scheduling conflicts and availabilities.

Verification

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Patient Request A Chart Copy Through MedChart (Follow This Link)

Third Party Request A Chart Copy Of A Patient
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Quick Message

Send us an Email for Quick Response

Verification

Here Are Our Coordinates

Referral Form (For First Timers or For Updates)

Please fill out the form and send to us

Personal Details

Referral Details

Health Details

Eye Details

Other Details

Visit Preparation

Booking Preferences (Will try to Accommodate)

Verification

Quick Links

Find Us @

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Patient Request A Chart Copy Through MedChart (Follow This Link)

Third Party Request A Chart Copy Of A Patient Through MedChart (Follow This Link)

Quick Message

Send us an Email for Quick Response

Verification

Here Are Our Coordinates

Referral Form (For First Timers or For Updates)

Please fill out the form and send to us

Personal Details

Referral Details

Health Details

Eye Details

Other Details

Visit Preparation

Booking Preferences (Will try to Accommodate)

Verification

Quick Links

Find Us @

What are you looking at ?

Follow Us

Third Party Request A Chart Copy Of A Patient
Through MedChart (Follow This Link)