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New Patient Form

LASIK Self Test

How Old Are You? *

Let's Talk Vision!

How Would You Describe Your Vision? *

I can't read or see up close
I can't see things far away
I have astigmatism

Which of These Do You Wear Most Often? *

Glasses
Readers
Contacts
I Don't Wear Anything

Does Wearing Contacts or Glasses While Being Outdoors Or Playing Sports Bother You? *

It Does Bother Me
It Doesn't Bother Me

Let's See Into Your Future

Would You Like To Read Without Assistance? *

Yes Please!
I'm Fine The Way I Am

Would Work Be Easier Without Glasses or Contacts? *

Definitely Easier
Not Much Easier
Wouldn't Change At All

Tell Us About Yourself

Name *

We only use your private information to get in touch with you. Your info is safe with us.

Email Address *

We only use your private information to get in touch with you. Your info is safe with us.

Phone Number *

We only use your private information to get in touch with you. Your info is safe with us.

Do Any Of These Conditions Apply To You?

Rheumatoid Arthritis
Multiple Sclerosis
Lupus
Cataracts
Keratoconus
Diabetic Retinopathy
Prior Eye Surgery
Priror Serious Eye Injury
Pregnancy

Anything You Want Us To Know Before You Come?

Do You Need LASIK?

Are you a candidate for LASIK eye surgery?

Maybe you have been turned down for Laser Vision Correction?

Take our self test and find out. If you also schedule your Free Consultation and have LASIK surgery within 90 days we will provide you a $150 Credit Towards Designer Sunglasses at our optical store. We will also waive our pre operative exam fee (saves $150). This is a $300 VALUE!

Take our short LASIK self test and find out if LASIK is right for you.

Want To Learn More About LASIK Eye Surgery?

Learn More

Ready To Come See Us?

Request An Appointment

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