Name:
Phone:
E-Mail:

1. Do you have trouble seeing far away or up close?
   Up close
   Far away
2. How interested are you in being able to play sports without glasses and contacts?
   It's very important to me NOT to wear glasses for activities such as sports.
   It's not important to me. I do not mind wearing glasses.
3. What is your age?
   Under 21
   21 - 40
   40 - 69
   69+
4. Are you interested in seeing well up close (reading) without glasses?
   It's very important to me NOT to wear reading glasses.
   It's not important to me. I do not mind wearing reading glasses to see things up close.
5. Do you wear contact lenses or glasses?
   Glasses
   Contact lenses
6. Would your career or business activities improve if you were to become less dependent on glasses and contacts?
   Yes
   No
   Maybe
7. Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?
   Yes
   No