Sansum Clinic
Decrease (-) Restore Default Increase (+) font size
PrintEmail

Patient Information Form

The following questions will help Dr. Katsev determine the best course of action for your vision treatment.

You may either print out this form and bring it with you to your appointment or submit the online form below:



* Indicates required information
Name * 
Email Address * 
Mailing Address 1 * 
Mailing Address 2 
City * 
State * 
Zip * 
DOB *  (mm/dd/yyyy)
Age 
Referred by 




If Other, please specify:

Occupation 
Hobbies 
Emergency Contact * 
Emergency Contact Phone # * 
Do You Wear Glasses? * 






Do You Wear Contact Lenses? 



What kind of problems are you having with your current form of vision correction? 
Please Check All That Apply 









List of Current Medications 
Medical Allergies 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.
 

Sansum Clinic is an independent nonprofit healthcare organization providing the full spectrum of quality healthcare in our community.

Sansum Clinic, Laser Eye Care Center
29 West Anapamu Street
Santa Barbara, CA 93101
(805) 681-8951
email: lasik@sansumclinic.org

View Larger Map

© 2012 Sansum Clinic

Terms of Use