LASIK CANDIDACY TEST
Nielsen Eye Center
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your age group?
Under 18
19-39
40-59
60+
Without my glasses and contacts (check all that apply)
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
What do you usually wear?
Glasses
Contacts
Reading glasses
Do you have any of the following
Rheumatoid Arthritis
Lupus
Keratoconus
Prior Eye Surgery
I am currently pregant
Multipe Sclerosis
Cataracts
Diabetic Retinopathy
Prior services eye injury
None of the above
How interested are you in being able to enjoy outdoor activities and / or sports without glasses and contacts?
It's very important to me NOT to wear glasses for outdoor activities and / or sports
It's not important to me, I do not mind wearing glasses
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
Would your career or business activities improve if you were to become less dependent on glasses and contacts?
Yes
No
Maybe
Would you be willing to discuss this procedure and your candidacy with our coordinator?
Yes
No
Message
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