Vision Correction Evaluation


The following self evaluation tool is a short series of questions that will help determine whether or not you are a candidate for refractive surgery. Your answers will be sent directly to our refractive surgery staff who will contact you as soon as possible to discuss your options.

Please be sure to fill in your name and your email address and/or phone number so that we may contact you and discuss your future without glasses or contacts.

1) What type(s) of corrective lenses do you use? (Check all that apply.)
Prescription eyeglasses
Dollar store reading glasses
Contact lenses
None of the above
2) Without my glasses and/or contacts:
I have trouble reading and seeing things at arms length
I have trouble driving and seeing things that are far away
I have trouble seeing things up close and at a distance
3) What is your age?
Under 18
19-30
31-40
41-50
51-60
60+
4) Would your career or extracurricular activities improve if you were to become less dependent upon glasses and/or contacts?
No
Yes
5)Have you ever had or been diagnosed with any of the following? (Check all that apply.)
Glaucoma
Astigmatism
Cataracts
Diabetic Retinopathy
Other eye surgery
Serious eye injuries
None of the above
6) Millions of people all over the world have benefited from LASIK and other vision correction surgeries. Despite the amazing outcomes of our patients and the safety precautions taken by our surgery staff, there are associated risks. Are you willing to discuss these risks with our surgeon and his staff?
No
Yes
7) How would you prefer our refractive surgery staff contact you? (Select all that apply).
Telephone  E-Mail  Postal Mail



8) Would you like to receive free information about your refractive surgery options by mail?
No
Yes



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