LASER EYE SURGERY

Laser Eye Surgery Evaluation form

First Name: Last Name

Address     

City             State Zip/Postal Code

Country       

Phone #      

Email Address 

If you know your prescription:

Right Eye 

Left Eye    

If you wear contact lenses check the appropriate box below:

Soft/daily /extended  Gas permeable  Toric contacts

Why do you want to have Laser eye surgery, also list your concerns?

What is your time frame?

Within 2 weeks 2 Weeks to a Month More than a month Not sure just gathering information