How old are you? *


 
Do you wear... *





 
Without your corrective lenses, do you have... *


 
Have you ever been told you have astigmatism?


 
Have you ever been told by your doctor that you have any of the following conditions:
*


 
Thank you for completing the self-test, however, based on your answers you may not be a suitable candidate for laser vision correction

 
Would you be open to a FREE no-obligation LASIK consultation (if it turns out your are a candidate)? *

     
 
What phone number can we call/text you at? *

 
Why do you want to find out if you're a candidate for LASIK? *


 
I want to find out if I'm a candidate for LASIK because... *

 
What's your first name? *

 
What's your last name? *

(Final Question)