Belmont Eye Center Make an Appointment

To Make an Appointment

Please fill out our Pre-Operative Questionnaire. Remember, vision correction procedures are open to individuals at least 18 years of age or older, so be sure you (or the person you have in mind) are eligible.

Note: Please make sure the form is completely filled out.

If you prefer, you may call us so we can answer your questions over the phone. When you call the office, please give the receptionist a brief description of your problem so that it can be handled appropriately. If you need to speak with Dr. Belmont, she will return your call at her earliest convenience.


First Name*
Last Name*
Date of Birth
Age
Occupation
Street Address 1
Street Address 2
City
State / Province
Zip
Country
E-Mail*
Phone*
If a doctor suggested you see us, please provide these information:
Doctor’s name
Phone
Address
----------
How did you hear about us?
Why are you interested in vision correction? (Please list all that apply)
Medical and Eye History
With eyeglasses or contacts on, how much nighttime glare or halos do you have?
List all eye surgeries, injuries or diseases you have had:
List all medical problems you have:
List all eyedrops you use, which eye, and how often you use them:
List any medication you are allergic to:
If female, are you or might you be pregnant?


* Required fields