Personal Information

Full Name *

Date of Birth *

Vision Information

Primary Vision Concern *

Do You Wear Glasses or Contacts? *

Glasses Contact Lenses Both Neither

Last Eye Exam Date

Eye Surgery History

Any Diagnosed Eye Conditions?

Do You Drive at Night?

Yes, regularly Sometimes No

Do You Experience Eye Strain or Headaches?

Frequently Occasionally Rarely Never

Insurance Provider

Interested in LASIK?

Yes, very interested Maybe, want to learn more Not interested

Preferred Exam Type *

Standard Eye Exam Pediatric Exam LASIK Consultation

Availability for Appointments *

Weekday Mornings Weekday Afternoons Weekday Evenings Weekends