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LASIK Survey
First Name
Last Name
Do you have trouble seeing far away or up close?
Far away
Up close
Both
How interested are you in being able to play sports without glasses and contacts?
Very
Not really
What is your age?
Under 21
21-40
40-69
69+
Are you interested in seeing well up close (reading) without glasses?
Yes
No
Do you wear contact lenses or glasses?
Contacts
Glasses
Both
None
Would your career or business activities improve if you were to become less dependent on glasses and contacts?
Yes
No
Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?
Yes
No
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