Lasik Self Evaluation Test | Eye Consultants of Texas

Name*

First Last

Phone

Email*

Do you have trouble seeing far away or up close?*

Up close
Far away

How interested are you in being able to play sports without glasses or 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
70+

Are you interested in seeing 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 wear glasses or contact lenses?*

Glasses
Contact lenses
Both
Neither

Would your career or business activities improve if you were to become less dependent on glasses or contacts?*

Yes
No
Maybe

Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. 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