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?

Select Your Answer*Kiss Country - Dina BPower 96 - JPHits 97.3 - DJ Laz99 Jamz - Rickey Smiley102.7 the Beach - Kenny Walker104.3 the Shark - Ashley O97.9 KVJ show - KevinYELPGoogleFacebookFriendOther

10. Where would you like the results sent to?

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