How old are you?
*
Under 18
19-44
45-65
66 & Up
What is your current vision (without) glasses?
*
I can't see far away.
I can't see close up.
I can't see anything.
What do you wear most? (90% of the time)This question is required.
*
Glasses
Contacts
Glasses & Contacts
Nothing
Have you ever had an eye injury or eye surgery in the past?
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Yes
No
Would you consider yourself to be generally healthy?
*
Yes
No
What is your biggest frustration with glasses / contacts? (Optional)
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What excites you most about the idea of life after LASIK? (Optional)
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Please enter your information so we can share your results with you....
Full Name
*
Mobile Phone
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Email
*
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