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?


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