Office Information
General Office Hours
Monday – Friday: 8am-4:30pm
Open for Patients at 6:15am
Phone 937.431.9531
Patient Forms
Like any licensed health care service provider, we are required to obtain specific information regarding our
patients and their unique circumstances to ensure the highest levels of quality care and service.
For your convenience, we have added downloadable patient forms below.
Please print and complete the questionnaire and email to This email address is being protected from spambots. You need JavaScript enabled to view it. or fax to our office at
(937) 431-9532 at least one week prior to surgery date.
If you are getting your pre-surgery physical from your Family physician make sure you have a copy of the
physical form. If you did not receive one in the packet that was mailed to you, print the one listed below.
If you take blood thinners.
If you take an injectable medication for diabetes or weight loss (GLP-1 Agonist) If you did not receive one in the
packet that was mailed to you, print the one listed below.
If you have had bypass surgery, stents, valve repair/replacements and/or pacemaker,
and some other cardiac conditions, Dayton Eye Surgery Center will require a cardiac clearance.
If a patient resides at a nursing home below is a packet that needs to be given to the patients care giver to
complete.