Lasik Candidate Quiz "*" indicates required fields Step 1 of 8 12% First Name* Last Name* Phone*Email* Preferred Contact*PhoneEmailHow Did You Hear About Us?*WebSocial MediaPhysicianInsuranceSeminarWord of MouthPrint AdOther What is Your Age Group?*Under 1819-4142-5050-6465+ Without glasses or contacts...(check all that apply) I have trouble reading and seeing things up close. I have trouble driving and seeing things far away. I have distorted vision and cannot see very well at any distance. What corrective lenses do you usually wear...(check all that apply)GlassesContact LensesReading GlassesNone Do you have any of the following?(check all that apply)Rheumatoid ArthritisCataractsPrior Eye SurgeryMultiple SclerosisKeratoconusPrior serious eye injuryLupusDiabetic RetinopathyPregnant or nursingNone of the above I would like to see well at a distance without relying on glasses and contact lenses.Rate this statement on a scale of 1 to 5 with 1 being the lowest. 1 2 3 4 5 I would like to see well up close without relying on glasses and contact lenses.Rate this statement on a scale of 1 to 5 with 1 being the lowest. 1 2 3 4 5 Would your lifestyle improve if you were to become less dependent on glasses and contact lenses? Yes No For Expert Eyecare, Cataract, Lens Replacement, LASIK, and More Call or Request an Appointment With Us Today! (855) 734-2020 Request Appointment
