Refractive Surgery Center

First

Last

Suffix

Date of Birth

Address

Address 2

City

State

ZIP Code

Email Address

Phone Number

How do you prefer to be contacted?

Phone

When is the best time to contact you?

Anytime

Morning

Afterno

Evening

How did you hear about us?

Why would you like a consultation?

Do you wear contact lenses?

Yes

Do you wear glasses? If so,

For distance

For reading

Bifocals

None

Have you had previous eye surgery? If yes, please briefly explain.