LASIK Self Test

Please fill out this form and we will get in touch with you shortly.

Name*
FirstLast
Phone*
Email*
Do you have difficulty seeing far away or up close? *
- Up Close
- Far Away
Would you prefer to be able to play sports without glasses and contacts? *
- It's very important to me NOT to wear glasses for activities such as sports.
- It's not important to me. I do not mind wearing glasses.
What is your age range?*
- Under 21
- 21 - 40
- 40 - 69
- 69+
Would you like to see well up close (reading) without glasses? *
- It's very important to me NOT to wear reading glasses.
- It's not important to me. I do not mind wearing reading glasses to see things up close.
Do you currently correct your vision with contact lenses or glasses?*
- Glasses
- Contact lenses
Would your lifestyle or business activities improve if you were to become less dependent on glasses and contacts?*
- Yes
- No
- Maybe
Over 98% of LASIK patients are thrilled with their vision after LASIK surgery. 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