Self-Exam Take the LASIK self-exam and one of our coordinators will contact you with your results. 1. Do you have trouble seeing up close or far away? a. Up closeb. Far Away 2. What is your age group? a. Under 21b. 21-39c. 40-59d. 60+ 3. Have you had any previous eye surgery? a. Yesb. No 4. How often does your prescription change? a. Rarelyb. Often 5. Does your profession include high contact sports? a. Yesb. No 6. Is your vision correctable with glasses or contacts? a. Yesb. No 7. Is your vision 20/20 with corrective eyewear? a. Yesb. No 8. Would similar results, or better with LASIK be acceptable? a. Yesb. No 9. Yes, I would like to schedule a consultation. The best time to call me is: a. 8am-12pmb. 12pm-4pmc. 4pm-7pmd. Please use email First Name Last Name Phone Number Email Address
