Do you wear glasses or contact lenses most of the time?
Are you in good general health?
Have you ever had a serious eye injury or eye surgery?
Have you ever had a herpes infection on your cornea?
Do you take any of these medications: Accutane®, Cordarone®, Methotrexate, Embrel®, Plaquenil®, or Gilenya®?
Are you pregnant or nursing?
Do you have any of the following vision problems?
Myopia (nearsightedness)Hyperopia (farsightedness)Astigmatism
How would you rate your quality of night vision?
Do you currently require reading glasses or bifocals?
Which is the most important issue for you regarding LASIK?
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?
Do you have any autoimmune disorder?
Your Name (required)
How did you hear about us?
BillboardEmployer/Health FairFamily/FriendHealth Care ProviderInsurance PlanPrint/NewspaperRadioWeb/InternetYellow PagesExisting PatientOther
Would you like our office to follow-up with you to schedule a free LASIK evaluation?