Berkeley Eye Center | Your Vision Partner in Houston

1

Which do you use most often?

Prescription Glasses

Contact Lenses

Over the Counter Readers

2

Without correction, do you have trouble seeing:* This field is required.Correction is the use of any prescription eyeglasses or contacts.

Up Close

Far Away

Both

3

Which best reflects your primary reason for wanting LASIK surgery?* This field is required.Please choose one.

I have an active or busy lifestyle

I look better without glasses

I do not like wearing contacts

I am too dependent on my glasses

I am too dependent on my contacts

My career would improve with LASIK

4

What is your primary concern with LASIK?* This field is required.Please choose one.

Affordability

The skill of my surgeon

Safety

Recovery time

5

Do you need brighter light for reading?* This field is required.

Yes

No

6

Have you been told you have any of the following conditions?

7

First & Last Name* This field is required.

First Name

Last Name

8

Phone NumberEntering your phone number authorizes Berkeley Eye Center to call you.

Please enter a valid phone number.

9

Text Message Opt InDo you authorize Berkeley Eye Center to text you. Message/data rates apply.

Yes

No

10

Email* This field is required.

example@example.com

11

Choose Your Preferred Location* This field is required.