Self Evaluation

1. What is your age group?

under 18 19-39 40-59 60+ Please select your Age
2. 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 that are far away I’ve been told that I have astigmatism Please describe your vision.
3. What do you usually wear? (Check All that Apply)

Glasses Contacts Reading Glasses Please select what you wear.
4. Do you have any of the following?

Rheumatoid Arthritis Multiple Sclerosis Lupus Cataracts Keratoconus Diabetic Retinopathy Prior Eye Surgery Prior serious eye injury I am currently pregnant None of the above Required
5. Yes, I would like to schedule a FREE Exam or Consultation. The best time to call me is: **

8am-12pm 12pm-4pm 4pm-7pm Please select when you would like to be contacted for your consultation
6. Please provide us with your contact information:

First Name:Required. Last Name:Required. Email Address:A Valid Email is Required. Phone Number: Area Prefix Suffix ––
7. Would you like to receive a Free LASIK Info Kit?

Yes, Please mail my kit to the following address

Street Address:
City: Required. State: Required.Zip Code: Required.

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