Your Age (All Fields Required)

Do You Suffer From:

NearsightednessFarsightednessAstigmatism

Do You Know Your Prescription?

0 to +50 to -5-5 to -10-10 or higherI don't know

Has Your Prescription Been Stable For The Last Year?

YesNoI don't know

Do You Have Trouble Seeing Distance Or Near Without Corrective Lenses?

YesNoBoth

What Type of Eyewear Do You Use Now?

Eyeglasses OnlySoft Contact Lenses OnlyBoth Eyeglasses and Soft Contact LensesSoft Toric Contact LensesGas Permeable Rigid Contact LensesNone of the Above

Do You Wear Reading Glasses Or Bifocals?

Yes, Reading GlassesYes, BifocalsNo

How Would You Rate Your Quality of Night Vision?

Good Night VisionFair Night VisionPoor Night Vision

Do You Have Any Of The Following Conditions?

Rheumatoid ArthritisKeratoconusCataractsCurrently PregnantNone of the Above

Have You Ever Had An Eye Injury Or Surgery?

YesNo

Has Anything Kept You From Having LASIK In The Past?

How Did You Hear About Us?

FacebookRadioFriendWebsiteGoogle SearchOther (Please specify below)Referring Doctor (Please specify name)

The answers to these questions will give us a general guideline for your candidacy for LASIK, the results of which we will provide. However, this short questionnaire is NOT a substitute for a proper medical examination and is simply a guide to help you determine if LASIK should be on your 'to do' list. The only way to know if LASIK surgery is right for your eyes is to have a thorough LASIK Examination.

First Name

Last Name

Email Where Results Will Be Sent

Phone

If you are a candidate would you like us to contact you to schedule your free consultation?

YesNo

DiStefano Eye Center has my permission to contact me and I can rescind this permission at any time.Permission To Contact

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