Lasik Self-Evaluation Test Step 1 of 7 14% EmailThis field is for validation purposes and should be left unchanged.My Age Is....(Required) UNDER 18 18-39 40 - 59 60+ You are under the age limit for his procedure please try again when you are older than 18. I usually wear:(Required) GLASSES CONTACTS READING GLASSES Without my glasses or contacts, I have trouble(Required) Seeing things that are far away, such as with driving Seeing objects up close, such as with reading I have been told that I have astigmatism(Required) Yes No I have or had the following(Required) Prior eye surgery Cataracts Keratoconus Diabetes Lupus Currently Pregnant/Nursing Prior Serious Eye Surgery Dry Eye Problems Herpes of the Eyes Rheumatoid Arthritis Multiple Sclerosis None of the Above My Contact Information Is...Name(Required) First Last Phone(Required)Email(Required) Preferred Contact Method (select one)(Required)Preferred Contact Method (select one)TextCallEmail
