Lasik Self Test

*Name:

*Phone:

*Email:

Do you have difficulty seeing far away or up close?

Up Close
Far Away
Both

Do you primarily wear contact lenses or glasses?

Contact Lenses
Glasses

What are your goals for pursuing laser vision correction?

To pursue an active lifestyle free from glasses or contact lenses
  To improve yor career or business actvities through reducing your dependency on glasses or contact lenses
To improve your appearance

Describe your level of importance for seeing well up close and without glasses:

Very important-You want to be completley free of glasses for reading
Somewhat important-You prefer not to wear reading glasses,but you are fine to wear them occasionally
Not important-You do not mind wearing glasses for reading

What is your age?

Under 25
25-45
45-65
65+

Although the majority of patients achieve excellent functional vision after Laser Vision Correction, it is important that each patient is educated on the minimal associated risk with the procedure. Would you like to discuss these risks and benefits with our Lasik coordinator?

YES
NO

captcha