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.
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: firstname.lastname@example.org.
Or call the Health Physics office at: 723-3201.