LASIK Self Evaluation

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

3

Date* This field is required.

Date

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.

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