LASIK Test

LASIK SELF TEST

* Indicates required field

Do you wear contact lenses or glasses? *

Contact Lenses Glasses

Is it important for you to be active without having to wear glasses or contacts? (Ex. swimming or sports) *

Important to NOT have glasses/contacts I don't mind wearing glasses/contacts

How old are you? *

Under 21 21 - 40 41 - 69 Over 69

Do you have trouble seeing far or close? *

Up Close Far Away

Would you like to be able to read without glasses? *

Important to NOT have glasses/contacts I don't mind wearing glasses/contacts

Would your job performance improve if you no longer had to wear glasses or contacts? *

Yes No Maybe

Are you interested in learning more about the procedure from our LASIK coordinator? *

Yes No

Name *

First

Last

Email *

Phone Number *

Submit

477 N. El Camino Real Suite C202
Encinitas, CA 92024
Tel: (760) 631-3500
Fax: (760) 753-5150

1930 Via Centre
Vista, CA 92081
Tel: (760) 631-3500
Fax: (760) 941-7448