What is your age range?

Under 18

18-29

30-39

40-54

55+

Are you currently pregnant or nursing?

Yes

No

Do you wear any of the following?

Glasses

Contact Lenses

Glasses & Contacts

Readers

Bifocals/Progressives

I don't wear glasses or contact lenses

Without your correctives, what vision issues do you currently have?

Trouble Seeing Far Away

Trouble Seeing Up Close

Overall Blurry Vision

Trouble with Reading Only

Have you ever been told you have astigmatism?

Yes

No

Do you have any of the following?

Cataracts

Glaucoma

Keratoconus

Macular Degeneration

Fuchs Dystrophy

Herpes Eye Infection

Pacemaker

Previous Vision Correction Surgery

None of These

Do you currently take Accutane medication?

Yes

No

What is your biggest concern with LASIK?

Affordability

Experience of Surgeon

Safety

Recovery Time

Almost Done!

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Would you like to schedule a free LASIK consultation?

Yes!

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