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Doctors
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Surgery
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Patient Portal

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LASIK quiz

Fill out the form below if you’re ready to learn more about LASIK and schedule a free evaluation.

What is your age range?*
- 21-29
- 30-39
- 40-54
- 55+
I most often wear:*
- Glasses
- Contacts
- Bifocals
- Readers
Without my glasses & contacts (check all that apply)*
- I have trouble reading and seeing things up close
- I have trouble seeing things from far away
- I have been told that I have astigmatism
How do you use your eyes on a daily basis outside of work? (check all that apply)*
- Reading
- Outdoor activities
- Sports / Fitness
- Scrapbooking/Sewing/Crafts
- Computer / Screen Time
- Other
Describe how do you use your eyes on a daily basis outside of work:
When choosing your vision correction surgeon, what matters most to you?*
- Affordability
- Convenience
- Safety
- Experience From Doctor
- Other
How soon would you consider laser vision correction?*
- ASAP
- Weeks
- Months
Do you have any of the following? (check all that apply)*
- Rheumatoid Arthritis
- Lupus
- Keratoconus
- Prior Eye Surgery
- Multiple Sclerosis
- I am currently Pregnant or Breastfeeding
- Cataracts
- Prior Eye Injury
- None of the Above
Name*
First Last
Email*
Phone*
Date of birth*
MM slash DD slash YYYY
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