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LASIK Self Candidacy Test 2018-07-12T22:14:57+00:00

LASIK Self Candidacy Test

Do you wear glasses or contact lenses most of the time?
GlassesContacts

Are you in good general health?
YesNo

Have you ever had a serious eye injury or eye surgery?
YesNo

Have you ever had a herpes infection on your cornea?
YesNo

Do you take any of these medications: Accutane®, Cordarone®, Methotrexate, Embrel®, Plaquenil®, or Gilenya®?
YesNo

Are you pregnant or nursing?
YesNo

Do you have any of the following vision problems?
Myopia (nearsightedness)Hyperopia (farsightedness)Astigmatism

How would you rate your quality of night vision?
GoodFairPoor

Do you currently require reading glasses or bifocals?
YesNo

Which is the most important issue for you regarding LASIK?
ResultsAffordabilitySafety

Do you know studies show you have as much as 10 times greater risk contracting a sight-threatening infection from wearing contacts than from getting LASIK?
YesNo

Do you have any autoimmune disorder?
YesNo

Your Name (required)

Phone (required)

Email (required)

How did you hear about us?

Would you like our office to follow-up with you to schedule a free LASIK evaluation?
YesNo

 
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