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LASIK Self-Test
Take a moment and find out if you may be a good candidate for LASIK eye surgery.
9
Questions
START
HIPAA
Compliance
1
What is your age group?
*
This field is required.
18 or under
19-39
40-59
60+
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2
Do you wear...
*
This field is required.
(check all that apply)
Glasses
Contacts
Reading glasses
None of these
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3
Without my glasses and contacts...
*
This field is required.
(check all that apply)
I have trouble reading and seeing things close up (Farsightedness)
I have trouble driving and seeing things far away (Nearsightedness)
I have distorted vision and cannot see very well (Astigmatism)
None of the above
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4
Have you been diagnosed, experienced, or are experiencing any of the following?
*
This field is required.
(check all that apply)
Cataracts
Diabetic Retinopathy
Keratoconus
Lupus
Multiple Sclerosis
Prior Eye Surgery
Prior Serious Eye Injury
Pregnant or Nursing
Rheumatoid Arthritis
None of these
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5
Would your lifestyle improve if you were less dependent on glasses and contact lenses?
*
This field is required.
YES
NO
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6
I would like to see well at a distance without relying on glasses and contact lenses.
*
This field is required.
YES
NO
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7
I would like to see well up close without relying on glasses and contact lenses.
*
This field is required.
YES
NO
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8
Name
*
This field is required.
First Name
Last Name
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9
Email
*
This field is required.
example@example.com
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10
Calculation
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