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LASIK Evaluation

LASIK Evaluation

What is your age group?

Under 18
19-39
40-59
60+

What do you usually wear?

Glasses
Contacts
Reading Glasses

Do you have any of the following?

Prior Eye Surgery
Prior serious eye injury
Keratoconus
Cataract
Diabetic Retinopathy
I am currently pregnant
Dry Eye Syndrome
Rheumatoid Arthritis
Multiple Sclerosis
Lupus
None of the above

Without my glasses and contacts

I have trouble reading and seeing things up close
I have trouble driving and seeing things far away
I have been told that I have astigmatism

How interestsed are you in being able to enjoy outdoor activities and/or sports without glasses and contacts?

Very much interested
Not of much interest

Are you interested in seeing well up close reading without glasses?

It's very important to me
It's not important to me

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

Yes
No
Maybe

Please provide us with the following contact information so that our executive can get in touch with you.