LASIK Self Evaluation

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LASIK Self-Evaluation

Hi there. Please fill out our free self-evaluation to see if you might be a good candidate for LASIK.

11Questions

1
Please select your age group* This field is required.
Under 18
19-39
60+
40-59
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Date* This field is required.
Date
Year
Month
Day
4
What do you usually wear?* This field is required.
Glasses
Contacts
Reading Glasses
5
Without my glasses and contacts...* This field is required.
I have trouble reading and seeing things up close
I have trouble driving and seeing things far away
I've been told that I have astigmatism
6
Do you have any of the following?* This field is required.
Rheumatoid Arthritis
Lupus
Keratoconus
Prior Eye Surgery
I am Currently Pregnant
Multiple Sclerosis
Cataracts
Diabetic Retinopathy
Prior Serious Eye Injury
None of the Above
7
Can we get your name?* This field is required.
First Name
Last Name
8
What is your phone number?
Area Code
Phone Number
9
What is your email?* This field is required.
example@example.com
10
What is the best way to contact you?
Phone
Email
11
I consent to receiving email communications.* This field is required.
Yes
No
Should be Empty:

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