Step 1 of 11 9% WELCOME TO OUR LASIK SELF TEST1. PLEASE SELECT YOUR AGE RANGE(Required) UNDER 18 19-39 40-59 60+ 2. DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?(Required) Diabetes Rhuematoid Arthritis Lupus Pregnancy/Nursing Other Auto Immune diseases None 3. Please select the eyewear you currently use(Required) Glasses Contacts Glasses & Contacts None 4. How often does your prescription change?(Required) Every year Every other year Every 5 years No recent changes 5. Without your corrective lenses, you...(Required) Struggle seeing far away Struggle seeing close up Struggle reading Have overall blurry vision None 6. Is your vision correctable with glasses or contacts?(Required) Yes No 7. Check all that apply(Required) I have been diagnosed with an astigmatism I have been diagnosed with cataracts I have blurry vision I strain to focus on objects I experience eye muscle pain I experience dry eye symptoms None 8. Check all that apply(Required) I've had previous eye surgery I participate in contact sports I lead an active lifestyle/play sports None 9. Which is the most important issue for you regarding your vision correction procedure?(Required) Achieving 20/20 vision Affordable fees Experienced surgeon Convenience 10. WHAT IS YOUR NAME(Required) YOUR FIRST NAME YOUR LAST NAME Please enter your contact information below!(Required) YOUR PHONE NUMBER(Required)Contact method you prefer(Required) Email Phone Text Your contact information will only be used internally at Lusk Eye Specialists to communicate with you regarding the results of your self-test. You’re information will not be shared elsewhere.
