EmailMe Form - Are you a lasik candidate.com form

Your Age

Do you Suffer From
(check all that apply)

Nearsightedness

Farsightedness

Astigmatism

Do you know your prescription?

Do you have trouble seeing
distance or near without
corrective lenses?

Distance Only

Near Only

Both

What typer of eyewear do
you use now?
(check all that apply)

Eyeglasses Only

Contact Lenses Only

Both Eyeglasses and Contact Lenses

None of the Above

Do you wear reading glasses
or bifocals?

Yes, Reading Glasses

Yes, Bifocals

No

How would you rate your
quality of night vision?

Good Night Vision

Fair Night Vision

Poor Night Vision

Do you have any of the
following conditions?
(check all that apply)

Keratoconus

Cataracts

Currently Pregnant

None of the Above

Have you ever had an eye
injury or eye surgery?

Yes

No

What is your main
expectation from
having LASIK?

Lifestyle Improvement

Tired of glasses/contacts

General better vision

What has kept you from
having LASIK in the past?

How did you hear about us?

Referring Doctor

Thanks for taking the time to
fill out this short LASIK
Self-Evaluation. Dr. Simon
will review your answers and
send you an email about your
candidacy. Please provide us
with your contact information
and we will send you your results.

Name *

First Last

Email *

Cell Phone Number *

### - ### - ####

REMEMBER: The answers to these
questions will give us a general
guideline as to your candidacy and
expected outcome, the results of
which we will provide. However,
this short questionnaire is NOT
a substitute for a proper medical
exam. If you are a candidate would
you like us to contact you to schedule
your free exam and evaluation?

Which office location
would you prefer?

Concord

Foster City

Which Day Of The Week
Would You Prefer?

What Time Of The Day
Would You Prefer?

Thanks for taking the time to fill out this short LASIK Self-Evaluation. Dr. Simon will review your answers and send you an email about your candidacy. Please provide us with your contact information and we will send you your results.

Thanks for taking the time to
fill out this short LASIK
Self-Evaluation. Dr. Simon
will review your answers and
send you an email about your
candidacy. Please provide us
with your contact information
and we will send you your results.