Assessment Request Form

A Qualified Doctor will personally discuss your options with you after performing a thorough and comprehensive refractive assessment to determine your candidacy for laser vision correction or refractive eye surgery. We utilize only the latest in diagnostic and surgical equipment and Lasers to maximize the safety and precision of each procedure.

Please fill in the Assessment Request Form below

First Name (required)

Last Name (required)

Date of Birth (required)

Gender (required)
FemaleMaleRather not sayOther

Which city are you from? (required)

Your Email (required)

Your Phone Number (required)

Occupation (required)

I am interested in: (required)

If "Other", please specify below

Do you wear contact lenses, glasses, or both? (required)
Contact LensesGlassesBoth

Current Prescription of Glasses/Contact Lenses:
(Please enter "Not Sure" below if unsure)

Right Eye (required)

Left Eye (required)

Who is your Optometrist?

Have you had any previous eye surgeries or eye injuries? (required)
YesNo

If "Yes", please specify below

Do you have any health conditions? (required)
(Example: Auto-immune disease, High blood pressure, Diabetes, etc.)

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