LASIK Self Test

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

Please Take our LASIK Self Test