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)