LASIK Evaluation Intake Form
Please complete this LASIK Evaluation Intake Form to help us prepare for your upcoming consultation. All fields are required for a thorough pre-evaluation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you currently wear glasses or contact lenses?
*
Glasses
Contact Lenses
Both
Neither
Have you had any previous eye surgeries or procedures?
*
Yes
No
Do you have any of the following eye conditions? (Select all that apply)
*
Dry eyes
Keratoconus
Cataracts
Glaucoma
None of the above
Other
Do you have any medical conditions (e.g., diabetes, autoimmune disorders) or take medications that affect your eyes?
*
Yes
No
What is your main reason for considering LASIK?
*
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