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* 1. How old are you?

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* 2. Select your Gender

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

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* 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?

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

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

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

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

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* 9. Do you have an astigmatism?

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

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* 11. Please enter your contact information below

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