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 closeFar awayBoth

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.GlassesSoft contact lensesToric soft contact lensesGas permeable lenses

What is your age?
Reading fine print.Using a computer or cooking.Driving a car.Under 2121 - 4040 - 6960+

Are you interested in seeing well up close (reading) without glasses?
It's very important to me NOT to wear reading glasses. First ChoiceIt'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?
YesNoMaybe

Do you know your visual prescription?

Do your eyes hurt after prolonged eyewear use?
YesNo

Do you have astigmatism?
YesNo

Has your prescription been stable over the last two years?
YesNo

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?
YesNo

If you have been told that you are not a candidate for LASIK, would you like to hear about other possible options?
YesNo

Lasik Consultation
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