Your Name (required)

Your Email Address (required)

Your Phone Number (required)

How old are you?
Under 2121 to 3031 to 3940 to 5556 to 6465 or older

Are you in generally good health?
YesNo

Do you have an active lifestyle?
YesNo

Do you wear glasses or contact lenses most of the time?
GlassesSoft contact lensesHard contact lensesReading glasses only

Has your prescription changed significantly in the last 2 years?
YesNo

Which of the following do you have?
Myopia (nearsightedness; trouble seeing distances)Hyperopia (farsightedness; trouble seeing close up)AstigmatismPoor night visionDon't know

Do you suffer from any of the following conditions?
DiabetesRheumatoid arthritisAutoimmune disease such as lupus, herpes simplex, herpes zoster, HIV, AIDSMultiple SclerosisCollagen vascular diseaseI am currently pregnantAs far as I know, I have none of these conditions

Have you previously had cornea surgery?
YesNo

Have you been diagnosed with any of these eye conditions?
KeratoconusGlaucomaCataractsRetinal diseaseSevere dry eyeCorneal scarringAs far as I know, I have none of these conditions

Do you currently take any medications that may slow your healing (such as steroids or immunosuppressant drugs)?
YesNo

What is the MAIN reason you are interested in LASIK eye surgery?
Cosmetic appearance (I want to look better)Glasses and contacts are a nuisance/hassle or uncomfortableEliminate restrictions on sports or leisure activitiesEliminate limitations on work activitiesI want to be completely free from glasses and contact lenses

What is your biggest concern about getting LASIK surgery?
Affordable priceHaving the best outcomeFreedom from my glasses or contacts

Have you been told that you are NOT a good candidate for LASIK surgery?
(We can tell you about other options.)
YesNo

How soon would you like to improve your vision?
As soon as possible3 to 6 months6 months or moreNot sure

I would like more information about LASIK and alternatives. The best time of day to reach me is:
8am to NoonNoon to 4pm4pm to 7pm

 
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