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Name
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Have you had eye surgery before?
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No
If yes: Please list the following for up to three (3) of you most recent eye surgeries.
Would you be interested in other treatment options if you are not a LASIK candidate?
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Yes
No
Do you have trouble seeing far away or up close?
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Up close
Far away
How interested are you in being able to play sports without glasses and contacts?
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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?
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Under 21
21 – 40
40 – 69
69+
Are you interested in seeing well up close (reading) without glasses?
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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 contact lenses or glasses?
(Required)
Yes
No
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?
(Required)
Yes
No
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