LASIK Surgery Nevada – Laser Vision Correction

Do you wear glasses or contact lenses most of the time?

Glasses
Contacts

Are you in good general health?

Yes
No

Have you ever had a serious eye injury or eye surgery?

Yes
No

Have you ever had a herpes infection on your cornea?

Yes
No

Do you take any of these medications: Accutane®, Cordarone®, Methotrexate, Embrel®, Plaquenil®, or Gilenya®?

Yes
No

Are you pregnant or nursing?

Yes
No

Do you have any of the following vision problems?

Myopia (nearsightedness)
Hyperopia (farsightedness)
Astigmatism
None or Not Sure

How would you rate your quality of night vision?

Good
Fair
Poor

Do you currently require reading glasses or bifocals?

Yes
No

Which is the most important issue for you regarding LASIK?

Results
Affordability
Safety

Do you know studies show you have as much as 10 times greater risk contracting a sight-threatening infection from wearing contacts than from getting LASIK?

Yes
No

Do you have any autoimmune disorder?

Yes
No

Name*

First

Phone*

Email*

How did you hear about us?

Do we have permission to text you?*

Would you like our office to follow-up with you to schedule a free LASIK evaluation?

Yes
No

LASIK Candidacy Test