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Last Name*:
Email*:
Phone*:
City*:
Are you over 18 years of age?*
Are you currently breastfeeding, pregnant, or planning to become pregnant within the next 6 months?
Which of the following statements best reflects your primary reason for seeking LASIK surgery? (Please select only one.)
What is you main concern*?
Do you experience:*
Do you currently have any of these health conditions?
Do you currently have any of these eye conditions?
Are you currently using steriods or immunosuppressants (that could inhibit healing)?
Do you currently wear:*
Have you ever had Lasik before?*
Have you ever been evaluated for Lasik before?*
Has your vision changed in the last year or two?
Name of Insurance (if applicable)*
How did you hear about our screening?*
If other source, please elaborate:
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