Your Name:

Phone Number:

Your Email:

Do you have trouble seeing far away or up close?

Up Close Far Away Both, distance and reading vision

How interested are you in being able to play sports or perform other activities without glasses and contacts?

It is very important to me NOT to wear glasses for sports or other activities

It is not important to me. I do not mind wearing glasses

What is your age?

Under 18 18 - 65 65+

Are you interested in seeing well up close (reading) without glasses?

It is very important to me NOT to wear reading glasses

It is not important to me. I do not mind wearing reading glasses to see things up close.

Do you wear contact lenses, glasses, or reading glasses?

Check all that apply: Contacts Glasses Reading Glasses

Would your daily activities improve if you were to become less dependent on glasses and contacts?

Yes No Maybe

Ninety-five percent of our patients achieve 20/20 vision or better after their procedure. The results of 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

Comment:

Client privacy is important to us. If you have any questions please see our privacy policy here.

Some required fields were not properly filled in. Please scroll up and correct them.