iLASIK      intraLASIK      Customization      Conventional LASIK      Advance Surface Ablatation      PRK      Monovision      FAQs      Take Our LASIK Quiz      Try our iLASIK Simulator Name:* Email:* Address me as: Phone Message: And how did you hear about us? Google Yahoo texaslasik.net Other web search Upclose Sugarland Magazine Fort Bend Focus Other periodical Newspaper Radio Television Referred by friend Referred by doctor Seminar Other (Enter the letters as they are shown in the image above.)

By answering the question below, you will allow our laser vision correction counselor to begin evaluating your candidacy for LASIK. Our counselors will call you to confirm and clarify your answers and arrange for you to come in for a complimentary in - office LASIK consultation. This is the only way we can be certain whether LASIK can work for you. Be sure to include a phone number and email address where we can contact you. Do you have trouble seeing far away, up close, or both? Far Way Up Close Both Do you presently wear glasses, contact lenses, or both? Glasses only Contact lenses only Both Has your glasses/contact lens prescription significantly changed in the last 12 months? Yes No     What is your age? Under 18 18-21 21-40 40-59 60 or over Are you interested in seeing well up close (e.g. reading) without glasses? It's very important to me NOT to wear reading glasses. It's not important to me. I do not mind wearing reading glasses to see things up close Do you suffer from any eye diseases such as dry eyes? Yes No I don’t know Are you currently being treated with medications such as steroids or immunosuppressants? Yes No I don’t know Have you ever been diagnosed with a connective tissue disorder, autoimmune disorder, or rheumatologic disorder such as lupus or rheumatoid arthritis? Yes No I don’t know Have you ever had a herpes eye infection? Yes No I don’t know No Have you ever had an eye injury? Yes No I don’t know Are you pregnant or nursing? Yes No I don’t know All surgeries carry some risk. Are you willing to discuss these risks with us? Yes No I don’t know Is there any other information you would like us to know? Name: Address me as: Email: Phone: How did you hear about us? Select Google Yahoo texaslasik.net Other web search Upclose Sugarland Magazine Fort Bend Focus Other periodical Newspaper Radio Television Referred by friend Referred by doctor Seminar Other Security code entry

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