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LASIK Self-Evaluation Test

Home> Procedures>LASIK Laser Vision Correction>LASIK Self-Evaluation Test

Curious about whether you might be a candidate for LASIK or another vision correction (refractive surgery) procedure? Please submit this brief form, and our Surgery Counselor will contact you with more information.

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Name

Phone

Age

Do you have trouble seeing far away or close up?

What do you currently use to correct your vision?

Have you ever been screened for LASIK?

Yes

Have you ever been told that you are not a candidate for LASIK?

Yes

If so, please describe what you were told.

If you have high nearsightedness, irregular corneas, or Keratoconus, you may be a candidate for new, advanced technologies to correct your vision. Would you like to learn more about these advanced technologies and whether you may be a candidate?

Yes

What is the timeframe you are considering for your vision correction procedure?

Would you like to learn more about our financing options?

Yes

In a sentence or two, please describe your vision goals.

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