LASIK Self-Test LASIK Self-Test If you are a human and are seeing this field, please leave it blank. All fields are required. Name Phone Email How would you like to be contacted? Choose One Phone Email Do you have trouble seeing far away or close up? Far AwayClose UpBoth Do you wear glasses or contacts? GlassesContactsReading Glasses Have you tried monovision contacts? YesNo What is your age? Under 2121-4041-6969+ What are you most interested in? Choose One iLASIK (blade-free) Visian ICL KAMRA™ Corneal Inlay Lens Replacement Surface Laser Correction Have you had prior vision correction surgery (LASIK/PRK/RK)? YesNo How interested are you in being without glasses and contacts? It is important to NOT to wear glasses or contacts while activeIt is not important to me; I don't mind wearing glasses Are you interested in seeing well up close (reading) without glasses? It is very important to me NOT to wear reading glassesIt is not important to; I don't mind wearing reading glasses to see up close Would your career or business activities improve if you were to become less dependent on glasses or contacts? YesNoMaybe Do you use a computer? YesNo How many hours per day? 1 - 3 hours 4+ hours Do you do a lot of driving at night? YesNo Approximately when was your last eye examination? Less than a year1 to 3 yearsMore than 3 years Choose the description that best describes your personality. extremely easygoingusually easygoingcan be a perfectionistextreme perfectionist How did you hear about us? Choose One Internet Family/Friend Seminar/Webinar Social Media Staff Member Newspaper Email Radio Billboard Magazine What is 10 + 10?
