Brinton Vision Lasik Self Test - Brinton Vision Intake

I most often wear*

glasses

contacts

readers

none of these

What is your age range?*

15-44

45-55

56-106

Without my glasses I have trouble reading street signs*

yes

no

Without my contacts I have trouble reading street signs*

yes

no

Without my readers I have trouble reading street signs*

yes

no

I have trouble seeing street signs*

yes

no

I've been told I have astigmatism*

yes

no

LASIK can now correct astigmatism!

Without my glasses I have trouble reading my cell phone*

yes

no

Without my contacts I have trouble reading my cell phone*

yes

no

Without my readers I have trouble reading my cell phone*

yes

no

I have trouble reading my cell phone*

yes

no

How well do you see at night?*

very well

ok, but could do better

quite poorly

When choosing your vision correction surgeon, which factors matter most to you?*

experience of the surgeon

technology

safety

affordability

convenience

Would your life improve if you were less dependent on glasses and contacts?*

absolutely!

maybe

not really

Clear eyesight, every waking moment, makes people more active and healthy!

If you are a candidate, when would you like to have your procedure?*

ASAP

next few months

More than three months out

Most LASIK patients return to work the next morning!

During clinic hours, one of our knowledgeable staff members will typically call you within one minute to walk you through our process and schedule you for your consultation!

Name*

First Last

Phone*

Email*