LASIK Self Evaluation

Your Name (required)

Your Phone

Your Email (required)

How did you hear about us?

Do you have trouble seeing far away or close up?
 Up close Far away Both

What is your current method of vision correction method?
 It's very important to me NOT to wear reading glasses. It's not important to me. I do not mind wearing reading glasses to see things up close. Glasses Soft contact lenses Toric soft contact lenses Gas permeable lenses

What is your age?
 Reading fine print. Using a computer or cooking. Driving a car. Under 21 21 - 40 40 - 69 60+

Are you interested in seeing well up close (reading) without glasses?
 It's very important to me NOT to wear reading glasses. First Choice It's not important to me. I do not mind wearing reading glasses to see things up close.

Would your career or business activities improve if you were to become less dependent on glasses and contacts?
 Yes No Maybe

Do you know your visual prescription?

Do your eyes hurt after prolonged eyewear use?
 Yes No

Do you have astigmatism?
 Yes No

Has your prescription been stable over the last two years?
 Yes No

Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?
 Yes No

If you have been told that you are not a candidate for LASIK, would you like to hear about other possible options?
 Yes No