Refractive Pre-Surgery Form

CONTACT DETAILS

PROCEDURE INFORMATION

OTHER 3rd PARTY SURGICAL COSTS ESTIMATE - REFRACTIVE

Please be advised: 

1. There are other separate costs involved for your laser vision corrective surgery apart from your surgeons fees, these are for the:

  • Laser facility

2. We have no control over costs and the below price guide is given as a rough estimate only as these are separate business to Sydney Eye Surgeons.

One Eye: $1100       Both Eyes: $2200
Please note:
As a service to our patients, we provide the following estimate of facility fees, which is separate to the surgeons fees. This is not a consent for surgery, by signing the below states that you have read, understood and agree to the above.

One Eye: $1600       Both Eyes: $3200
Please note:
As a service to our patients, we provide the following estimate of facility fees, which is separate to the surgeons fees. This is not a consent for surgery, by signing the below states that you have read, understood and agree to the above.

One Eye: $1600       Both Eyes: $3200
Please note:
As a service to our patients, we provide the following estimate of facility fees, which is separate to the surgeons fees. This is not a consent for surgery, by signing the below states that you have read, understood and agree to the above.

One Eye: $1700       Both Eyes: $3400
Please note:
As a service to our patients, we provide the following estimate of facility fees, which is separate to the surgeons fees. This is not a consent for surgery, by signing the below states that you have read, understood and agree to the above.

Draw signature|Type signatureClear

All further information regarding admissions can be found in your surgical information pack.



To be completed by the patient prior to surgery

List all medications you are taking:

List all complementary medicines you are taking e.g. vitamins:

WHO SHOULD WE CONTACT IN CASE OF EMERGENCY

PRIVACY ACT: We are committed to providing exceptional customer service and care. We acknowledge our obligations to you under the Privacy act of 1988 (as amended).Personal information we collect from you will be used primarily to ensure that you receive optimal care, but may be released to third parties as part of mandatory reporting requirements.

Draw signature|Type signatureClear