At LaserVue, we believe that making the most informed decision about your visual needs and choosing the correct procedure/surgeon is very important. Please answer the following questions to help determine if vision correction surgery may be for you.

A LASIK surgery patient coordinator will be in touch with you to review your answers and discuss suitability.

1. *My name is: 2. My phone number is: (Include Area Code) 3. *My e-mail address is: 4. What is your age? Under 18 18 to 39 40 to 59 over 60 5. Has your prescription for glasses or contact lenses changed in the last 1 year? Yes   No 6. Do you have any medical eye conditions? Yes   No   Don't know 7. Do you have any of the following medical conditions: diabetes, autoimmune (e.g. lupus, rheumatoid arthritis) or immunodeficiency disease (e.g. AIDS)? Yes   No 8. Are you currently taking medications that may impair healing or with any ocular side effects? Yes   No   Don't know 9. Are you pregnant/nursing or expect to be soon? Yes   No 10. What type of vision problem do you have? Select One Nearsightedness (Myopia) - Difficulty seeing at distance Farsightedness (Hyperopia) - Difficulty seeing up close Astigmatism with/without Myopia or Hyperopia - All images are blurry 11. Do you wear reading glasses? Yes   No   Don't know 12. What is your main reason for considering vision correction? Select One Improve my lifestyle For my career My contact lenses are uncomfortable Eliminate my need for glasses or contact lenses 13. Have you been evaluated to determine if you are a candidate for LASIK surgery before? Yes   No 14. How soon would you like to have vision correction surgery? Select One Within the next one month 2-6 months Don't know Form may take a few moments to send. *Denotes required fields.