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LASIK Self Evaluation

Determine if you are a candidate for LASIK and tell us a little about yourself by filling out the online form below. Our staff will contact you within 24 hours to assist you.

Name: *
Email Address: *
Phone: ( ) - - *

  1. Without glasses or contacts, do you have trouble seeing up close or far away?
    Up close
    Far away

  2. What is your age group?
    18 - 21
    21 - 49
    49 - 65
    Over 65

  3. Any previous eye surgery?
    Yes
    No

  4. How often does your prescription change?
    Every year
    Every other year
    Every 5 years
    No recent changes

  5. Does your profession or hobbies include high impact sports?
    Yes
    No

  6. Is your vision correctable with glasses or contacts?
    Yes
    No

  7. Is your vision close to 20/20 with corrective eyewear?
    Yes
    No

  8. Would similar results - or better - with LASIK be acceptable?
    Yes
    No

 

                    

 

 

Office Hours: Monday through Friday
8:00am - 4:00pm
10 Chatham Heights Road
Fredericksburg, VA 22405
|PH| 540-371-2777
|PH| 800-572-2722
|FX| 540-371-0922

 

10 Chatham Heights Rd.     •     Fredericksburg, VA 22405     •     540-371-2777