LASIK Self-Test

1

What is your age group?* This field is required.

Under 18

19-39

40-59

60+

3

Without my glasses and/or contacts...* This field is required.

I have trouble reading and seeing things up close

I have trouble driving and seeing things far away

I have trouble seeing at all distances

I have been told that I have an astigmatism

4

How interested are you in being able to enjoy outdoor activities and /or sports without glasses and contacts?* This field is required.

It is very important to me to NOT wear glasses for outdoor activities and/or sports

It is not important to me. I do not mind wearing glasses

5

Are you interested in seeing well up close (reading) without glasses?* This field is required.

It is very important to me NOT to wear reading glasses

It is not important to me. I do not mind wearing reading glasses to see things up close

7

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

Yes

No

Maybe

8

Would you be willing to discuss vision correction options and your candidacy with our surgical coordinator?

Yes

No

Send me an email

9

What is your first name?* This field is required.

10

What is your last name?* This field is required.

11

Where would you like us to email your results?* This field is required.

example@example.com

12

What Phone Number can we call you at?

Please enter a valid phone number.