First & Last Name:
How did you hear about us?
1. Do you have trouble seeing far away or up close?
2. How interested are you in being able to play sports without glasses and contacts?
3. What is your age?
4. Are you interested in seeing well up close (reading) without glasses?
5. Do you wear contact lenses or glasses?
6. Would your career or business activities improve if you were to become less dependent on glasses and/or contacts?
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 risks. Are you willing to discuss these risks with one of our LASIK coordinator?
(please type in the numbers
and/or letters in the white box)