LASIK Self-Test

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Do we have consent to text you?(Required)

What is your age range?(Required)

Under 50

50-60

Over 60

Do you wear glasses or contacts to correct your vision?(Required)

No

Prescription Glasses

Reading Glasses

Contact Lenses

Can you see up close without your prescription glasses?(Required)

Yes

No

Have your ever worn ‘Mono-Vision’ contact lenses?(Required)

Yes

No

Are you having difficulty driving at night?(Required)

Yes

No

Do you suffer from Dry Eyes (itchy/watery)?(Required)

Yes

No

Have you had any previous eye surgery?(Required)

Yes

No

Do you have a history of Ocular Eye Disease?(Required)

Yes

No

Is your glasses prescription changing every year?(Required)

Yes

No

Do you wear reading glasses?(Required)

Yes

No

Name

This field is for validation purposes and should be left unchanged.

Are You a LASIK Candidate?