Name
*
First Name
Last Name
Name
First and Last Name
Email
*
example@example.com
Do you have trouble seeing far away or up close?
Up Close
Far Away
How interested are you in being able to play sports or drive without glasses and contacts?
It's very important to me NOT to wear glasses for activities such as sports or driving.
It's not important to me. I do not mind wearing glasses.
What is your age?
21-40
40 - 69
69+
Are you more interested in seeing at distance (sports, driving) or close (reading) without glasses?
Distance
Close (reading)
Do you wear contact lenses or glasses?
Glasses
Contact Lenses
What are your primary reasons for wanting vision correction?
Family
Sports/Leisure
Work
Driving
Reading
Other
The results of LASIK laser vision correction are generally excellent. Despite the excellent safety and outcomes of LASIK, there are associated risks. Are you willing to discuss these risks with the doctor and our LASIK staff?
Yes
No
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