LASIK Self-Test

Step 1 of 9

Please select your age group: *

Which best describes your current vision? (Select all that apply)*

Myopia (near-sighted)

Hyperopia (far-sighted)

Astigmatism (distorted vision)

Presbyopia (need reading glasses or bifocals)

How are you currently correcting your vision? (Select all that apply)*

Single vision glasses

Bifocal or progressive glasses

Contact lenses

No correction

If you wear contacts, how many years have you worn them?

Share some activities that you would like to do without glasses or contacts:

Are you familiar with monovision? *

Are you familiar with monovision?*

Yes, and I liked it!

Yes, and I did not like it

Never heard of it or never tried it

Have you been told you are not a candidate for LASIK? *

Have you been told you are not a candidate for LASIK? **

Yes

No

Which of the follow best describes your personality?*

Relaxed and easygoing

Detail-oriented, but can relax when needed

Organized planner

Perfectionist

Please list your occupation:*

If you are not a candidate for LASIK, would you be interested in other refractive (vision-correcting) solutions?

How familiar are you with advanced technology solutions (Laser cataract surgery, Vivity IOL, PanOptix IOL, etc) for cataract surgery?*

How familiar are you with LASIK and other refractive (vision-correcting) procedures? *

How familiar are you with LASIK and other refractive (vision-correcting) procedures? **

Other Comments:

Name*

First Last

Phone*

Email

Preferred method of communication:*

Phone call

Text message

Email

Do we have your permission to send you text messages?*

Yes

No, do not contact me by text message