OnlineEvaluationforLaser

Take a few minutes to complete this form. It will help us make an initial assessment of whether you are a suitable candidate for refractive surgery.

Note: This questionnaire is an initial evaluation. Final eligibility is determined only after a detailed ophthalmological examination.

Contact Information

What is your age?

Have you had other eye surgeries in the past?

Currently, you wear:

What refractive errors or eye conditions do you have?

Select all that apply to you

Do you have any of the following conditions?

Select all that apply to you

Are you pregnant or breastfeeding?

Has your prescription been stable in recent months?

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