Lasik Quiz

Your Information

First Name *

Last Name *

Phone Number *

Email Address *

Your Age

Your Glasses / Contacts Information

Do you wear glasses?

Yes

No

Do you wear contacts?

Yes

No

Can you tell us your most recent glasses or contact lens prescription?

Yes

No

Which of the following conditions do you have (select all that apply)?

Myopia (Nearsightedness)

Hyperopia (Farsightedness)

Astigmatism

Are you in good general health?

Yes

No

Have you ever had eye surgery?

Yes

No

Have you ever had any eye injuries or diseases?

Yes

No

Have you ever been diagnosed with cataracts?

Yes

No

How well do you see at night?

Very Well

Okay

Poorly

Your Thoughts on LASIK

Which is the most important issue for you regarding LASIK?

Affordability

Safety

Experience of doctor

Being free of my glasses or contacts

Do you know what is involved in a LASIK procedure?

Yes

Possibly

No

How concerned are you about the safety of the procedure?

Very concerned

A little concerned

Not concerned

Have you ever had a LASIK evaluation before?

Yes

No

Your Contact Preference

How do you prefer to be contacted?

Phone only

Email only

No preference

Your Information

Your Glasses / Contacts Information

Your Thoughts on LASIK

Your Contact Preference

Ready To See Clearly?

Trust Your Vision To The Best