LASIK Self Test LASIK Self Test AM I A CANIDATE FOR REFRACTIVE SURGERY? How old are you? * Under 18 19-40 41-69 69+ I currently use (Select all that apply) * Contacts Glasses Reading Glasses None Has your prescription changed recently? * Yes No Approximately when did it change? Are you currently nursing, pregnant, or planning to get pregnant in the near future? * Yes No Did your eye doctor talk to you about LASIK? * Yes No Doctor's name * The #1 thing I am looking for in a LASIK Center (choose all that apply) * * Reputation of Surgeon Results Cost Financing I authorize an Ophthalmology Associates & LASIK Center Center representative to contact me to discuss the results of my LASIK Self-Test. I acknowledge that the information provided in this questionnaire will be used to send additional information about offers related to our services. * Yes Your name * Your Phone Number * Your Email Address Your Date of Birth * Where did you hear about Ophthalmology Associates? Submit If you are human, leave this field blank.