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Lasik Self Test
Are you a candidate for LASIK in St. Louis?
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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?
*
Affordability
Safety
Convenience
Experience of the surgeon
Technology
Other
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
Name
*
First
Last
Phone
*
Email
*
Email
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