Are You a Candidate for Lasik?

Lasik is a life-changing decision. We want to be sure you are getting the best possible experience and outcome with your Lasik surgery. Please take a moment to fill out this questionnaire regarding your current vision so that we may help you make an informed decision. Diana, our Vision Correction Facilitator, will contact you promptly.

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

What is your age group?*

18-39
40-69
61-100+

Describe your vision now*

(Check all that apply)

I have trouble driving and seeing far away without glasses or contacts.
I have trouble reading and seeing close without glasses or contacts.
I have trouble seeing both near and far.
I have been told that I have astigmatism.
I have had cataract surgery.

How do you correct your vision now?*

Glasses
Contacts
Bifocals
Readers only
No correction

What is your primary goal for Laser Vision Correction?*

Eliminating the need for glasses and contacts for most activities.
Eliminating the need for readers.
Better distance vision.

What are your concerns about Laser Vision Correction?*

(Check all that apply.)

Experience of doctor
Cost of surgery
Fear of pain during and after surgery
Results of surgery
Safety of surgery

What is the status of your interest in Laser Vision Correction?*

I am beginning to gather information.
I am ready for a FREE Lasik evaluation and consultation.
Sign me up!