LASIK Self Evaluation | Dallas / Fort Worth Eye Surgery Center

What is your age range?*

Which do you use most frequently?*

Do you have trouble seeing far-away or up-close? Check all that apply.

Do you have or suspect you have any of the following? Check all that apply.

Do you know your prescription today? If so, please list below:

Left Eye : Right Eye :

Which is the most important issue for you regarding your vision correction procedure?

If you were determined to be a good candidate, how soon would you like to have your procedure?

Name*

First Last

Email*

Phone*

Self Evaluation