LASIK Contact Form
Name
*
First Name
Last Name
Phone
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Have you had a stable glasses prescription for 2 years?
Yes
No
Are you able to see up close without glasses or contacts?
Yes
No
Have you been diagnosed with a condition such as Cataracts, Dry Eye, Keratoconus, Lupus, or Rheumatoid Arthritis?
Yes
No
Have you ever had a serious eye injury or eye surgery?
Yes
No
Submit Form
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