101 Old Short Hills Road, Suite 101, West Orange, New Jersey 07052 · 1-800-797-EYES · (973) 736-1313

ARE YOU A CANDIDATE for LASIK?

Corneal Associates of New Jersey
LASIK, Cataract Surgery, Cornea Specialists

For best results, please fill out this test completely.
Those marked with * are required for a response. Thank you.

How old are you?

Under 18
18 to 42
43 to 64
65 and older

You have difficulty seeing:

Far away
Near (reading vision)
Both

What type of vision correction do you wear? Check all that apply:

Glasses	how many years?
Soft contact lenses	how many years?
Toric soft contact lenses	how many years?
Gas permeable lenses	how many years?

Are you interested in seeing up close (reading) without glasses?

It is important for me NOT to wear reading glasses
It is unimportant for me. I do not mind wearing reading glasses to see up close.

How would your life improve by decreasing your dependence on corrective glasses or contacts?

What kind of work do you do?

What hobbies and activities are important to you?

Over 98% of patients, millions of Americans) have legal driving vision (20/40 or better) after vision correction surgeries. Despite the excellent safety profile of these surgeries, are you willing to discuss the risks with a LASIK coordinator and doctor at our practice?

If you prefer, our LASIK counselor could call, email, or mail information to you. (We would never distribute or sell address, phone or email lists.) When is the best time to call?

10.

* Name:
* Primary phone:
Second phone:
* Email:
Street:
City:
State:	Zip:

11.

Have you been told that you are a LASIK candidate?

12.

If you have been told that you are not a candidate for LASIK, would you like to hear about other possible options?

13.

Many patients tell us that deciding on vision correction surgery is a process. Where are you in the decision making process? Check all that apply:

I want a brief consult with a counselor
I want a consult and exam with a doctor
Price is my only question
I want to get financing and preapproval
I am ready to schedule surgery

None of the above: The information I need is as follows:

Schedule consult and / or exam

Financial preapproval

Reduce or eliminate your need for glasses and contacts - take your vision beyond glasses, beyond contacts, possibly beyond 20/20! Corneal Associates of New Jersey is here for you, offering complete and unbiased information and advice to help you choose the ideal treatment for your situation, resulting in your BEST POSSIBLE VISION. Call now for you appointment:

(973) 736-1313

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LASIK New Jersey

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Cataract Surgery New Jersey

CustomVue LASIK

Laser Vision Correction in New Jersey

If you are seeking LASIK in New Jersey our practice offers excellent quality and experienced LASIK surgeons.

CUSTOMVUE LASIK - LASER SURGERY, NEW JERSEY

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LASIK New Jersey - Corneal Associates is a premier LASIK and cataract eye surgery practice in West Orange, New Jersey, specializing in LASIK laser eye surgery, corneal transplantation and cataract surgery for areas including: North West Caldwell, Verona, Cedar Grove, Montclair, Bloomfield, Nutley, Belleville, Morristown, Irvington, Milburn, Maplewood, Livingston, East Orange, and Essex County.