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Eye Care

Laser Vision Self Evaluation

FREE Laser Vision Correction Self-Evaluation

This short questionnaire is NOT a substitute for a proper medical examination and is simply a guide to help you work out if Laser Vision Correction should be on your ‘to do’ list. The only way to know if Laser Vision Correction is right for your eyes is to have a thorough Laser Vision Correction Evaluation.

  1. What is your age group?*  under 18 21-40 40-65 65+

  2. Do You Suffer From:*  Myopia (Nearsightedness) Hyperopia (Farsightedness) Both Astigmatism

  3. Do You Usually Wear Glasses Or Contacts?*  Glasses Contacts Both

  4. Do You Currently Require Reading Glasses?*  Yes No

  5. Are You In Good General Health?* Yes No

  6. Have You Ever Had An Eye Injury Or Eye Surgery?*  Yes No

  7. Have you ever been diagnosed with diabetic retinopathy, Keratoconus, Lupus or Rheumatoid Arthritis?* Yes No

  8. What is your main expectation from having Laser Vision Correction?* A positive impact on my lifestyle (better appearance, freedom to play sports, etc) Better vision in general

  9. Please provide us with your contact information:

    First Name*

    Last Name*

    Email Address*
    Phone Number*