814-616-3067
311 W. 24TH ST. SUITE 401, ERIE, PA 16502 814-455-7591
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Lasik Self Test
Take our self test to see if lasik eye surgery is right for you, or call our LASIK Coordinator for a FREE Consult @
814-455-7591
Name
*
First
Last
Phone
Email
*
Do you start your day by putting on glasses or contacts?
Yes
No
Do you currently use any vision correction?
Glasses
Contacts
Both
Neither
Do you have any trouble seeing up close or far away?
Up close
Far away
Both
Neither
What is your age range?
Under 21
21 - 45
46-68
69+
What is your profession?
Professional / Office
Physical / Hard Labor
Other
If other please specify
*
Do you live an active lifestyle or play sports?
Yes
No
Do you have an auto-immune disorder, diabetes, or other health concerns?
Yes
No
If yes please specify
*
Rate your uncorrected vision on a scale of 1 - 10 (1 being poor, 10 being great).
1
2
3
4
5
6
7
8
9
10
How long has it been since your last eye exam?
Less than one year
1 year ago
2 year ago
3 year ago
4+ years ago
Have you discussed lasik with your eye doctor?
Yes
No
Have you had eye surgery before?
Yes
No
Over 98% of lasik patients see 20/40 or better after surgery. The results of lasik laser vision correction have been tremendous for millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our lasik coordinator?
*
Yes
No
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