1 What is your age group?

Under 18 19-39 40-59 60+

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2 Without my glasses and contacts... (Check All That Apply)

Without my glasses and contacts

Farsightedness : I have trouble reading and seeing things up close‎ Nearsightedness : I have trouble driving and seeing things far away‎ Astigmatism : I have distorted vision and cannot see very well‎

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3 What do you usually wear? (Check All That Apply)

What do you usually wear?

Glasses‎ Contacts‎ Reading Glasses‎ None of Them‎

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4 Do you have any of the following? (Check All That Apply)

Do you have any of the following?

Dry Eyes‎ Keratoconus‎ Glaucoma‎ Macular Degeneration‎ None of the above‎

Why do you want your vision corrected?

I want visual freedom to improve my lifestyle I want to save money over time Tired of the hassle of glasses and contacts

Which of the following are important to you?

I want to meet the surgeon who will perform the procedure‎ I want to know my options beyond LASIK‎ I want to know about the affordability of LASIK‎ I want to know that the technology used is modern, not outdated‎ All of the above‎

Like any medical procedure there are risks associated with LASIK vision correction. Are you willing to discuss these risks with our staff?

Yes No

What are you looking for in a surgeon?

Experience‎ Safety‎ Competence & Solid Outcomes‎ All of the above‎

How are you looking at this procedure?

My safety with high quality with top technology is most important Price is the most important part of this decision

10 Would your lifestyle improve without glasses and contact lenses?

Yes No

11 Would you like to Schedule a Free Screening?

Let us know what’s preventing you from getting LASIK:

Would you like to Schedule a Free Screening?

Yes No

Test Score

Is the patient a candidate?