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LASIK Self Evaluation
Name
*
First
Last
Phone
Email
*
Do you have trouble seeing far away or up close?
*
Up close
Far away
How interested are you in being able to play sports without glasses and contacts?
*
First Choice
Second Choice
Third Choice
What is your age?
*
Under 21
21-40
41-60
60+
Are you interested in seeing well up close (reading) without glasses?
*
It is very important for me to NOT wear reading glasses.
It is not important for me. I do not mind wearing reading glasses to see things up close.
Do you wear contact lenses or glasses?
*
Glasses
Contact lenses
Would your career or business activities improve if you were to become less dependent on glasses and contacts?
Yes
No
Maybe
Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?
Yes
No
Maybe
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