LASIK Self-Evaluation Test

First Name: *

Last Name: *

Email: *

Phone: *

What is your age?

Under 18
18 - 40
40 - 50
50+

Do you have dry eye problems?

None
Mild
Moderate
Severe

Has your glasses or contact prescription been stable for at least 12 months?

Yes
No
Not sure

Do you wear reading glasses or bifocals?

Yes, Reading Glasses
Yes, Bifocals (or Trifocals)
No

Have you ever had an eye injury or eye surgery?

Yes
No

Over 98% of LASIK patients see 20/20 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

Questions/Comments?

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