ARE YOU A CANDIDATE for LASIK?

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

1.	How old are you? Under 18 18 to 42 43 to 64 65 and older
2.	You have difficulty seeing: Far away Near (reading vision) Both
3.	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?
4.	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.
5.	How would your life improve by decreasing your dependence on corrective glasses or contacts?
6.	What kind of work do you do?
7.	What hobbies and activities are important to you?
8.	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?
9.	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: Home Cell Work    Second phone: Home Cell Work * 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