Name * Email * Phone Number * How did you hear about us? * Friend Referring Doctor Google Search Instagram Facebook Newspaper / Magazine Radio Other How did you hear about us? Additional Comments Do you have trouble seeing far away or up close? Up close Far away Both What is your current method of vision correction? Glasses Soft contact lenses Toric soft contact lenses Gas permeable lenses What is your age? Under 21 21-40 40-69 69+ Would your career or business activities improve if you were to become less dependent on glasses and contacts? Yes No Maybe Do you know your visual prescription? +6.00 +5.75 +5.50 +5.25 +5.00 +4.75 +4.50 +4.25 +4.00 +3.75 +3.50 +3.25 +3.00 +2.75 +2.50 +2.25 +2.00 +1.75 +1.50 +1.25 +1.00 + .75 + .50 - .50 - .75 -1.00 -1.25 -1.50 -1.75 -2.00 -2.25 -2.50 -2.75 -3.00 -3.25 -3.50 -3.75 -4.00 -4.25 -4.50 -4.75 -5.00 -5.25 -5.50 -5.75 -6.00 -6.25 -6.50 -6.75 -7.00 -7.25 -7.50 -7.75 -8.00 -8.25 -8.50 -8.75 -9.00 -9.25 -9.50 -9.75 -10.00 -10.25 -10.50 -10.75 -11.00 -11.25 -11.50 -11.75 Do your eyes hurt after prolonged eyewear use? Yes No Has your prescription been stable over the last two years? Yes No Over 92.6% of LASIK patients treated with our Contoura Vision Topography Guided LASIK see 20/20 or better after surgery, and literally millions of people have benefitted from LASIK. Despite the proven safety, there are associated risks. Would you like to discuss the risks and benefits with our LASIK coordinator? Yes No Are you pregnant or nursing? Yes No If you are human, leave this field blank.
(763) 421-7420
Fax: (763) 421-0730
