Sansum Clinic
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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)
Referred by 

If Other, please specify:

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 * 

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

Sansum Clinic, Laser Eye Care Center
4151 Foothill Road
Santa Barbara, CA 93110
(805) 681-8951

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