How old are you?

Question Title

* 1. How old are you?

Select your Gender

Question Title

* 2. Select your Gender

Which of the following statements best reflects your primary reason for seeking LASIK surgery? (Please select one)

Question Title

* 3. Which of the following statements best reflects your primary reason for seeking LASIK surgery? (Please select one)

Like any surgical procedure, LASIK has risks involved, and complication-free procedures can result in less than 20/20 vision. Are you willing to educate yourself about those risks, accept reasonable risk if you are an appropriate candidate, and comply with a schedule of post-surgery medications and follow-up exams?

Question Title

* 4. Like any surgical procedure, LASIK has risks involved, and complication-free procedures can result in less than 20/20 vision. Are you willing to educate yourself about those risks, accept reasonable risk if you are an appropriate candidate, and comply with a schedule of post-surgery medications and follow-up exams?

Do you have any of the following conditions? (Please select all that apply)

Question Title

* 5. Do you have any of the following conditions? (Please select all that apply)

Are you currently taking any medications, such as steroids or immunosuppressants, which can slow or prevent healing?

Question Title

* 6. Are you currently taking any medications, such as steroids or immunosuppressants, which can slow or prevent healing?

Do you have any of the following conditions? (Please select all that apply)

Question Title

* 7. Do you have any of the following conditions? (Please select all that apply)

What type of refractive error do you have?

Question Title

* 8. What type of refractive error do you have?

Do you have an astigmatism?

Question Title

* 9. Do you have an astigmatism?

Has your vision correction - that is, your glasses or contact lens prescription - changed over the past year or two?

Question Title

* 10. Has your vision correction - that is, your glasses or contact lens prescription - changed over the past year or two?

Please enter your contact information below

Question Title

* 11. Please enter your contact information below

T