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

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 matters to you? *

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

Absolutely!
No way.
Maybe?

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

Next few weeks
Next few months
> 3 months out

By submitting this form, you understand that you will receive a phone call, email, and text message from Brinton Vision to help you get scheduled for your Brinton Vision Ocular Analysis (BVOA).

Name *

First

Last

Phone *

Email *

Are you a candidate for LASIK in St. Louis?