Laser Eye Examination Pre-Placement Form

Request for Pre-Placement Laser Eye Examination
 (for Users of Class 3B and 4 lasers)

 

 
To communicate requests to have an eye examination fill out and submit the form, below. After submitting the form, wait two days, then call the Ophthalmology Clinic at The Palo Alto Medical Foundation (650-853-2974, ask for Laura Buttler) to schedule an appointment. Be sure to identify yourself as being with Stanford University and desiring a "Preplacement Eye Exam" under the contract for such service (so you won't be billed.) Health Physics will have given the Clinic your name.

If you don't wish to have the examination please complete the
STATEMENT DECLINING PREPLACEMENT EYE EXAM  form

to obtain the waiver form which should be printed out and sent by I.D. mail to Health Physics at ESF, 480 Oak Road, Mail Code 8006.

For assistance on laser safety questions call Arefeh Shanjani, 725-1411; e-mail: arefehs@leland.stanford.edu.
Or call the Health Physics office at: 723-3201.

 

EYE EXAM REQUEST FORM

FIRST Name:

LAST Name:

Middle Initial:

LAST 6 DIGITS of your Social Security Number:
X X X -

Department or Division where you work with lasers:

Building and Room number where laser installation is located:

Principal Investigator:

Phone Number where you can be reached:

Email Address:

Additional Comments:

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