Take The LASIK Self Evaluation Test

1. Do you have trouble seeing far away or close?

Select Your Answer*Far awayUp closeBothNeither

2. What do you currently use to correct your vision?

Select Your Answer*GlassesContact lensesBothNeither

3. What is your age?

Select Your Answer*18-3940-5555+

4. Do your glasses and contacts interfere with recreational or daily activities?

Select Your Answer*YesNo

5. What is your main concern with Laser Vision correction?

Select Your Answer*AffordabilitySafetyExperience of doctorOther

6. What are your primary reasons for wanting vision correction?

Select Your Answer*Save TimeSports/LeisureWorkDrivingReadingOther

7. Have you had a vision correction consultation before?

Select Your Answer*YesNo

8. If you are a candidate, are you interested in a Free LASIK Consultation?

Select Your Answer*YesNo

9. How did you hear about us?

How Did You Hear About Us1*Kiss Country - Dina BPower 96 - Ivy UnleashedHits 97.3 - DJ Laz/Miss Bryan99 Jamz - Big MackHot 105 - Rickey Smiley104.3 the Shark - Ashley O97.9 KVJ show - Kevin610 WIOD News Radio - Reno Grant93.9 MIA - Reno Grant104.7 The Bull - Reno GrantYELPGoogleFacebookFriendOther

10. Where would you like the results & information sent to?

Patient Type

New PatientExisting Patient

(*) Fields Are Mandatory