Self Evaluation Test

Your Name (required)

Phone (required)

Email (required)

1. Do you have trouble seeing far away or up close?
 Up Close Far Away

2. How interested are you in being able to play sports without glasses and contacts?
 Very Important Not Important

3. What is your age?
 Under 21 21 - 39 40 - 69 70+

4. Are you interested in seeing well up close (reading) without glasses?
 Very interested Not interested

5. Do you wear contact lenses or glasses?
 Contact Lenses Glasses

6. Would your career or business activities improve if you were to become less dependent on glasses and contacts?
 Yes No Maybe

7. 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 risk. Are you willing to discuss these risks with our LASIK coordinator?

 Yes No