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Contact Information
Name
Phone Number
E-mail Address
Next
What is your age?
18-29
30-39
40-54
55+
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Next
Without glasses or contacts, do you have trouble:
seeing far away
reading or seeing things up close
seeing far away and up close
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Do you have any of the following conditions?
Cataracts
Diabetic Retinopathy
Lupus
Prior Eye Surgery
Rheumatoid Arthritis
Currently Pregnant or Breast Feeding
Keratoconus
Multiple Sclerosis
Prior Serious Eye Injury
None of the Above
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Have you had a LASIK consultation before?
Yes
No
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Would you like to:
Be able to see in the distance without glasses or contact lenses
Be able to read without glasses or contact lenses
I don’t mind glasses or contact lenses. I just want improved vision when wearing them.
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How did you hear about St. Paul Eye Clinic?
I'm currently a St. Paul Eye Clinic patient.
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