Cataract Surgery LASIK Orange County
 

LASIK Self Candidacy Test

Harvard Eye Associates is so much more than a LASIK clinic. Certainly, LASIK is the most popular form of vision correction, but we also offer an array of excellent options that might be better for some patients. Please take a moment to complete the form below so that we may have a better understanding of your vision and lifestyle demands. After completing the form, our vision correction coordinator will contact you to discuss the first step toward a possible lifestyle without glasses or contacts!
  * Red denotes required information
First Name: *
Last Name: *
Phone: *
Email: *
  1. Do you have trouble seeing far away or up close?

    Up close
    Far away
    Both, distance and reading vision

  2. Do you play sports or have other activities where it would be beneficial to NOT have to wear glasses?

    It's very important to me to NOT wear glasses for sports or other activities.
    It�s somewhat important to me. They interfere in some activities.
    It's not important to me. I do not mind wearing glasses.

  3. What is your age?

    Under 21
    21 - 40
    41 - 55
    Over 55

  4. If you�re over the age of 40, how important is it to you to be able to READ without glasses? Are you OK wearing reading glasses as long as you see well in the distance?

    It's very important to me to NOT wear reading glasses.
    It is somewhat important to me.
    It's not important to me. I do not mind wearing reading glasses to see things up close.

  5. What do you currently wear? Check all that apply.

    Contact lenses
    Glasses
    Reading Glasses

  6. How strong is your current prescription?

    Mild
    Medium
    Strong

  7. Has your prescription been changing significantly every year, enough that you can't wait to get to the eye doctor because you can't see well enough?

    Yes
    No

  8. Have you ever had previous eye surgery?

    Yes
    No

 

 

MEDICAL AND PRIVACY WARNING:
Email and web page inquiries are usually reviewed within 1-2 business days. Urgent or private medical information should not be sent by email or via our web page. If you have a medical emergency, please call 911 or your local emergency medical system by telephone. Information transmitted by email or via our website may be viewed by others, and Harvard Eye Associates cannot guarantee the privacy of any information transmitted in this way.

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Cataract Surgery LASIK Orange County