:: SITE LAST UPDATED: Mar 11, 2010

Schedule A No Charge Pre-LASIK Exam To See If You Are A Good Candidate

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LASIK Self Evaluation

This brief self-evaluation will help you determine whether you are a candidate for LASIK. After completing this evaluation, we will email you a general explanation of the questions and a personalized result based on your answers. You also have the option of receiving a call to discuss your results.

This evaluation should take no more than 2 minutes.

Q1. Date of Birth (m/d/y):
A1.
Q2. Age or grade you started wearing glasses?
A2.
Q3. When you first started wearing glasses, were they more for reading or more for distance?
A3.	They were more for reading. They were more for distance.
Q4. What types of eye-wear do you use now? (check all that apply)
A4.	Contact Lenses Prescription Eyeglasses Dime Store Reading Glasses None of the above
Q5. Have you ever worn or tried Contact Lenses?
A5.	Yes No
Q6. How would you rate your quality of night vision?
A6.	Good Night Vision Fair Night Vision Poor Night Vision
Q7. Do you have any of the following conditions? (check all that apply)
A7.	Rheumatoid Arthritis Keratoconus Cataracts Currently Pregnant None of the Above
Q8. Anything else we should know about your general health or eye health?
A8.
Q9. What has kept you from having LASIK in the past?
A9.
Please enter your name and contact info so that we can send you the results:
First:
Last:
Email:
Phone:
Address:
City:
State:
Zip:
Would you like us to CALL you with your results?
	Yes, please CALL with my results No, please just EMAIL my results
Comments or Questions:

NOTE: You should receive an email confirmation shortly after you submit this form. Please call us at 405-733-2020 if you don't receive it within a few minutes.

·	Our Doctors
·	Gary Wilson, M.D.
·	Stephen Fly, O.D.
·	Stacey Rockett, O.D.

·	NASA Approves All-Laser Lasik
·	Getting LASIK To Save Lives
·	One Million Blade-Free

·	Learn about our prices and No Interest (0%) payment plan options.

·	We have links to other sites that may help you.

·	Schedule a consultation with our doctors. Tell us when you would like to visit.

VISIT US AT: 7101 NW Expwy, Suite 335, Oklahoma City, OK 73132
PHONE: 405-733-2020 | 1-888-733-2020 | FAX: 405-721-1411
EMAIL: laservision@clearsight.com
OFFICE HOURS: 8:30-5:00 M-F