1- To start, please tell us how old you are: *

Under 45

45-60

60+

2- Do you have to wear glasses/contacts for...? *

Driving

Computer

Reading

All of the above

3- Have you ever been told you have astigmatism? *

Yes

No

4- Have you ever been told you have a cataract?

Yes

No

5- Is your current prescription...

Higher than -8 (ex. -9, -10, -11...)

Lower than -8 (ex. -6, -5, -4...)

I'm farsighted (ex. +1, +2, +3...)

I'm not sure

6- Have you had any of the following procedures on your eyes (LASIK, PRK, RK, Cataract Surgery)? *

Yes

No

*This does not disqualify you from Modern Vision Correction

7 - What is your first name? *

What is your last name? *

What email should we send the results to? *

8- Phone *

I agree to receive SMS text messages from King LASIK