Your Contact Information:

1. Do you have trouble seeing in the distance, or up close?
     Distance
     Up close
    

2. How important is it to you that you are able to participate in activities such as sports WITHOUT glasses or contacts?
     It is very important to me that I NOT wear glasses or contacts during activities such as sports
     It's not very important to me, I don't mind wearing glasses or contacts
    

3. How old are you?
     Under 21 years old
     21 - 40 years old
     41 - 69 years old
     70 or older
    

4. How important is it to you that you are able to see well up close (reading) WITHOUT glasses?
     It is very important to me that I NOT wear reading glasses to see well up close
     It's not very important to me, I don't mind wearing reading glasses to see up close
    

5. Do you currently wear glasses or contact lenses?
     I wear glasses
     I wear contact lenses
     I don't wear glasses or contacts
    

6. Would your career opportunities improve if you were less dependent on glasses or contacts?
     Yes!
     No
     Maybe
    

7. Over 98% of our patients see 20/40 or better right after surgery. Laser vision correction has helped millions of people see better. Although the safety and results of laser vision correction is outstanding, there are associated risks. Are you ready to discuss these risks with Dr. Shealy
     Yes!
     No
    

8. I understand that in order to have my consultation and surgery on the same day, that I need to discontinue wearing my contact lenses.
     I wear soft contact lenses and will take them out one to two days before my appointment.
     I wear soft toric lenses and will take them out one to three weeks before my appointment.
     I wear hard contacts and will take them out four to six weeks before my appointment.
     I wear rigid contacts and will take them out one month for each decade of wear before my appointment.
     I don't wear contact lenses.
    

9. I am interested in the VIP Laser Vision Correction Promotional Offer and would like to make arrangements for group pricing!
     I have a friend interested in the VIP Laser Vision Correction Promotional Offer and may have surgery with me.
              is is my friend's name.
              is my friend's phone number or email address.
     I have more than one friend interested in group pricing that may have surgery with me, call me for their names.
           (Make sure you have entered your phone number in the space at the top of this form so we can call you.)