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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.
11
Questions
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HIPAA
Compliance
1
Please select your age group
*
This field is required.
Under 18
19-39
60+
40-59
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2
Date of Birth
*
This field is required.
-
Date
Year
Month
Day
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3
Date
*
This field is required.
-
Date
Year
Month
Day
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4
What do you usually wear?
*
This field is required.
Glasses
Contacts
Reading Glasses
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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
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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
Rheumatoid Arthritis
Lupus
Keratoconus
Prior Eye Surgery
I am Currently Pregnant
Multiple Sclerosis
Cataracts
Diabetic Retinopathy
Prior Serious Eye Injury
None of the Above
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7
Can we get your name?
*
This field is required.
First Name
Last Name
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8
What is your phone number?
Area Code
Phone Number
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9
What is your email?
*
This field is required.
example@example.com
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10
What is the best way to contact you?
Phone
Email
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11
I consent to receiving email communications.
*
This field is required.
Yes
No
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