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LASIK Quiz

The only way to know if you’re a true candidate for LASIK is to have a thorough professional evaluation. If you are interested in scheduling a free LASIK Evaluation please fill in your contact information, answer every question, and hit submit. Deanna Alter, LASIK Coordinator, will contact you within one business day.

Name: *
Phone: *
Email: *
Age:
Do you wear glasses or contact lenses?
Glasses
Contact Lenses
Both
Are you in good general health?
Yes
No
Have you ever had eye surgery?
Yes
No
Have you ever had any eye injuries or diseases?
Yes
No
Which of the following conditions do you have (select all that apply)
Myopia (Nearsightedness)
Hyperopia (Farsightedness)
Astigmatism
How well do you see at night?
Very Well
OK. but could be better
Poorly
Do you use reading glasses or bifocals?
Yes
No
What is the most important issue for your regarding LASIK?
Affordability
Saftey
Experience of doctor
Being free of my glasses or contacts
Do you know what is involved in a LASIK procedure?
Yes
Possibly
No
Are you concerned that the risks outweigh the benefits of LASIK
Yes
Possibly
No
Have you ever had a LASIK evaluation before?
Yes
No

© 2012 Del Negro & Senft Eye Associates
1809 Corlies Avenue #1
Neptune Township, Monmouth NJ 07753