Self Evaluation


1. What is your age group?

 

2. Without my glasses and contacts: (check all that apply)

 

3. What do you usually wear? (Check All that Apply)

 

4. Do you have any of the following?

 

5. Yes, I would like to schedule a FREE Exam or Consultation. The best time to call me is: **

 

6. Please provide us with your contact information:

 

7. Would you like to receive a Free LASIK Info Kit?

 

Street Address: 
City:  State: Zip Code: