1234 Welcome To Your LASIK Candidacy QuizFill out the form below to get started!Name* First Last Email* Phone*Zip Code* Birthday (MM/DD/YYYY)* Is LASIK the right choice for you?Without my glasses and contacts:*(Check all that apply) I have trouble reading and seeing things up close I have trouble driving and seeing things far away I have been told that I have astigmatism Is LASIK the right choice for you?Do you wear any of the following?*(Check all that apply) Glasses Contacts Reading Glasses Is LASIK the right choice for you?Do you have any of the following?*(Check all that apply) Cataracts Keratoconus Uncontrolled Diabetes Pacemaker Prior Eye Surgery Prior Serious Eye Injury I am currently pregnant/nursing None of the above NameThis field is for validation purposes and should be left unchanged.
