Appointment - A Guide to Understanding Your Eyes - Orange Grove Center for Corrective Eye Surgery

<body bgcolor="#FFFFFF" text="#000000" link="#000080" vlink="#800000"> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="4" width="100%"> <tr> <td valign="bottom" colspan="3"> <p align="center"><img border="0" src="../images/top_noframes.gif" width="590" height="85"></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td valign="top" width="103%" colspan="3"> <table border="0" cellpadding="0" cellspacing="4" width="96%"> <tr> <td valign="bottom" colspan="3"><font face="Verdana, Helvetica, Arial" size="2"><img border="0" src="../images/Titula_Appointment.gif" alt="Appointment" width="259" height="45"></font></td> </tr> <center> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td valign="top" width="103%" colspan="3"> <hr> <script Language="JavaScript"></script><form METHOD="POST" action="../_vti_bin/shtml.dll/Appointment/index.htm" onsubmit="return FrontPage_Form1_Validator(this)" name="FrontPage_Form1" webbot-action="--WEBBOT-SELF--" target="_self"> <input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"> <p><font face="Verdana, Helvetica, Arial" size="2">If you would like to make an appointment with our office or visit us for a complimentary consultation for LASIK, please fill out and submit the Confidential Medical History form on this website. You may also print this page and fax it to us at (520) 797-2235.The form is confidential. </font></p> <p><font face="Verdana, Helvetica, Arial" size="2">Please provide the following <font color="#800000">CONFIDENTIAL medical history</font>:</font></p> <table> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>First Name</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="First_Name" SIZE="25"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>Last Name</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Last_Name" SIZE="25"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>Address</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Address" SIZE="35"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>City</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="City" SIZE="35"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>State/Province</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="State" SIZE="35"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>Zip/Postal code</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Zip" SIZE="12" MAXLENGTH="12"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>Country</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Country" SIZE="25"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>Phone</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Phone" SIZE="25" MAXLENGTH="25"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>FAX</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="FAX" SIZE="25" MAXLENGTH="25"></font></td> </tr> <tr> <td ALIGN="right"><font face="Verdana, Helvetica, Arial" size="2"><em>E-mail</em></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Email" SIZE="25"><img border="0" src="../images/yes.gif" width="10" height="8"></font></td> </tr> </table> </center> <table> <center> </center> <center> </center> <tr> <td colspan="2" bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Appointment Information:</b></font></td> </tr> <tr> <td> <p align="right"><font face="Verdana, Helvetica, Arial" size="2">What do you like to be called?</font></p> </td> <center> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="What_do_you_like_to_be_called" SIZE="25"></font></td> </tr> </center> <tr> <td> <p align="right"><font face="Verdana, Helvetica, Arial" size="2">Today's Date:</font></p> </td> <center> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Date" SIZE="25"></font></td> </tr> </center> <tr> <td> <p align="right"><font face="Verdana, Helvetica, Arial" size="2">What days of the week are best for you?</font></td> <td> <p align="left"><input type="text" name="days_of_the_week_are_best_for_you" size="25"></td> </tr> <tr> <td> <p align="right"><font face="Verdana, Helvetica, Arial" size="2">What times of day are best?</font></td> <center> <td><font face="Verdana, Helvetica, Arial" size="2"><input type="text" name="What_times_of_day_are_best" size="20"></font></td> </tr><tr> <th align=left colspan=2 bgcolor="#000080"><font color="#FFFFFF" size="2" face="Verdana, Helvetica, Arial">Please answer the following important questions about your health:</font></th> </tr><tr> <td colspan=2><font face="Verdana, Helvetica, Arial" size="2">How can we help you during your visit to our office?</font> </tr><tr> <td colspan=2> <font face="Verdana, Helvetica, Arial" size="2"> <textarea rows="3" name="How_can_we_help_you_during_your_visit_to_our_office" cols="45" wrap=hard></textarea></font> </td> </tr><tr> <td colspan=2 bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Have you had recent major surgery?</b></font></td> </tr><tr> <td colspan=2> <table> <tr> <td><font face="Verdana, Helvetica, Arial" size="2">Type:<input NAME="Have_you_had_recent_major_surgery_Type1" SIZE="25"></font></td> <td><font face="Verdana, Helvetica, Arial" size="2">Date:<input NAME="Have_you_had_recent_major_surgery_Type1_date" SIZE="10"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2">Type:<input NAME="Have_you_had_recent_major_surgery_Type2" SIZE="25"></font></td> <td><font face="Verdana, Helvetica, Arial" size="2">Date:<input NAME="Have_you_had_recent_major_surgery_Type2_date" SIZE="10"></font></td> </tr></table> </td> </tr> <tr> <th align="left" colspan=2 bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF">List ALL present medications (over-the-counter and prescription):</font></th> </tr> <tr> <td colspan=2> <table> <tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_1" SIZE="25"></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_6" SIZE="25"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_2" SIZE="25"></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_7" SIZE="25"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_3" SIZE="25"></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_8" SIZE="25"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_4" SIZE="25"></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_9" SIZE="25"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_5" SIZE="25"></font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_present_medications_10" SIZE="25"></font></td> </tr> </table> </td> </tr><tr> <td colspan="2"> <table> <tr> <td bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>List ALL eye drops:</b></font> </td> </tr> <tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_eye_drops_1" SIZE="25"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_eye_drops_2" SIZE="25"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_eye_drops_3" SIZE="25"></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="List_ALL_eye_drops_4" SIZE="25"></font></td> </tr><tr> <td bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Who is your primary Doctor?</b></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Who_is_your_primary_Doctor" SIZE="25"></font></td> </tr><tr> <td bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Who referred you to our office?</b></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input NAME="Who_referred_you_to_our_office" SIZE="25"></font></td> </tr></table> </td> </tr><tr> <th colspan=2 align=left bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF">Allergic to any medications?</font></th> </tr><tr> <td colspan=2> <font face="Verdana, Helvetica, Arial" size="2"> <textarea rows="3" name="Allergic_to_any_medications" cols="45" wrap=hard></textarea></font> </td> </tr><tr> <td valign=top colspan="2"> <table> <tr> <td colspan=2 bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Do You Smoke?</b></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Do_You_Smoke" value="Yes">Yes</font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Do_You_Smoke" value="No">No</font></td> </tr><tr> <td colspan=2 bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Do You Drink?</b></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Do_You_Drink" value="Yes">Yes</font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Do_You_Drink" value="No">No</font></td> </tr><tr> <td colspan=2 bgcolor="#000080"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Do You Use Drugs?</b></font></td> </tr><tr> <td><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Do_You_Use_Drugs" value="Yes">Yes</font></td> <td><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Do_You_Use_Drugs" value="No">No</font></td> </tr><tr> <td colspan=2> <font face="Verdana, Helvetica, Arial" size="2">If yes, explain:<br> <textarea rows="9" name="If_yes_explain" cols="25" wrap=hard></textarea></font> </td> </tr></table> </td> </tr> </table> </center> <table> <tr> <th align=left colspan=3 bgcolor="#000080"> <font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Have you had eye surgery for:</b></font> </th> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2">Yes</font></th> <th><font face="Verdana, Helvetica, Arial" size="2">No</font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><br></font></th> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Cataracs" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Cataracs" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Cataracts</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Crossed_eyes" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Crossed_eyes" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Crossed Eyes</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Glaucoma" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Glaucoma" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Glaucoma</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Retinal_detachment" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Retinal_detachment" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Retinal Detachment</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Near_astigmatism" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Near_astigmatism" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Nearsightedness/Astigmatism</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Wear_glasses" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Wear_glasses" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Do you wear glasses?</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Wear_contacts" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Wear_contacts" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Do you wear contacts?</font></td> </tr><tr> <th colspan="3" bgcolor="#000080"> <p align="left"><font face="Verdana, Helvetica, Arial" size="2" color="#FFFFFF"><b>Family History:</b></font></th> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2">Yes</font></th> <th><font face="Verdana, Helvetica, Arial" size="2">No</font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><br></font></th> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Heart_disease" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Heart_disease" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Heart Disease</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Diabetes" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Diabetes" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Diabetes</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="High_Blood_pressure" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="High_Blood_pressure" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">High Blood Pressure</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Glaucoma_history" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Glaucoma_history" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Glaucoma</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Cataracs_history" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Cataracs_history" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Cataracts</font></td> </tr><tr> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Retinal_detach_history" value="yes"></font></th> <th><font face="Verdana, Helvetica, Arial" size="2"><input type="radio" Name="Retinal_detach_history" value="no"></font></th> <td><font face="Verdana, Helvetica, Arial" size="2">Retinal Detachment</font></td> </tr></table> <p align="left"> </p> <p align="left"><font face="Verdana, Helvetica, Arial" size="2">Comments:</font><br> <textarea rows="5" name="Comments" cols="45"></textarea></p> <center> <p><font face="Verdana, Helvetica, Arial" size="2"><input TYPE="SUBMIT" VALUE="Submit Form"> <input TYPE="RESET" VALUE="Reset Form"></font></p> </form> <hr> <form method="POST" action="../_vti_bin/shtml.dll/Appointment/index.htm" name="Confidential Medical History" webbot-action="--WEBBOT-SELF--" target="_self"> <input TYPE="hidden" NAME="VTI-GROUP" VALUE="1"></center> </td> </tr> </table> <p align="center"><img height="1" src="../linija.gif" width="96%"></p> <p align="center"> <marquee style="font-family: Verdana; color: #0000FF; font-style: italic; font-weight: bold" bgcolor="#FFFF00">Change the way you SEE...and change your LIFE!  Robert M. Kershner, MD, FACS and Chris M. Seniw, MD are two of Tucson's most experienced refractive specialists helping thousands of your friends and neighbors to see more clearly without the dependence on eyeglasses and contact lenses.  Shop around, but stop here. You will find the most qualified specialists, the best staff and the happiest patients.  The Eye Laser Center-Tucson, Arizona USA  Call or Contact us through this site NOW!</marquee> </p> <p align="center"><strong><font face="Verdana, Helvetica, Arial" size="1">| <a href="../index.htm" target="_top">Intro Page</a> | <a href="../a_site_for_eyes.htm" target="_top">Home Page</a> |<a href="../About_Us/whatsnews.htm" target="_top"> What's New </a> | <a href="../About_Us/index.htm" target="_top">About Us</a> | <a href="../Physicians/index.htm" target="_top">Physicians</a> |<br> | <a href="../Your_Eyes/index.htm" target="_top">Your Eyes</a>  | <a href="../Our_Specialties/index.htm" target="_top">Our Specialties</a> | <a href="index.htm" target="_top">Appointment</a> | <u><font color="#0000FF">More <a href="../FAQ-s/index.htm" target="_top">Your Eyes</a> </font></u> | <a href="../Location/index.htm" target="_top">Location</a> | <a href="../Contact_Us/index.htm" target="_top">Contact Us</a> |<u><a href="../About_Us/Eye_Laser_Center_Privacy_Policy.htm">Privacy Policy</a></u></font></strong></p> <p align="center"><img height="3" src="../linija.gif" width="96%"></p> <p align="left"><font size="1">*Individual results may vary. Persons over the age of forty are more likely to require glasses for reading. Sunglasses may be necessary when out of doors. As with all surgical procedures, there is no assurance or guarantee as to the outcome of the procedure.</font></p> <p align="left"><font size="1">This website is intended for educational purposes only.  It is not a substitute for medical advice from a physician. To schedule an appointment with one of our medical doctors, contact us on line, by phone <font color="#0000FF"> (520) 797-2020</font> or fax <font color="#0000FF"> (520) 797-2235</font>.  Use of this site constitutes an agreement with the user that releases the Eye Laser Center and Robert M. Kershner, MD, PC from any and all liability. </font></p> <p align="center"><img height="3" src="../linija.gif" width="96%"></p> <p align="center" style="line-height: 60%"><font face="Verdana, Helvetica, Arial" size="2"><b>E-Mail us at:</b> <a href="mailto:info@asiteforeyes.com"><b>info@asiteforeyes.com</b></a></font></p> <p align="center" style="line-height: 80%"><font face="Verdana, Helvetica, Arial" size="2" color="#FF0000"><b><i>Eye Laser Center</i><br> Robert M. Kershner, M.D., P.C., F.A.C.S.</b></font><font face="Verdana, Helvetica, Arial" size="1"><br> <b> SUITE 303, 1925 W. ORANGE GROVE ROAD<br> TUCSON, AZ 85704-1152<br> Phone: (520) 797-2020<br> Fax: (520) 797-2235</b></font></p> <p align="center" style="line-height: 60%"><span style="background-color: #FFFF00"><b><u><font face="Verdana, Helvetica, Arial" color="#0000FF" size="3"><a href="../Contact_Us/main.htm">SET YOUR SIGHT ON US...AND SET YOURSELF FREE!</a></font></u></b></span></p> <p align="center"><font face="Verdana, Helvetica, Arial" size="1">Best experienced with<br> <noindex><a href="http://www.microsoft.com"> <img src="../footer1.gif" width="88" height="31"></a></noindex><br> You must be running Internet Explorer 5.0.or later<br> <br> Designed & Developed by<br> <a href="../Physicians/Robert_Michael_Kershner.htm" target="_top"><font color="#0000FF">Robert M. Kershner, MD, FACS,<u> PC</u></font></a><br> Copyright © 1998-2003. All servicemarks, trademarks and copy herein are registered property of Robert M. 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