Am I a Candidate for LASIK?

Call or Text: 616.365.5775

Please complete the form below and we will follow up using your preferred method of contact:

First Name *

Last Name: *

Your Email: *

Phone Number: *

Date of Birth: *

Do you have astigmatism? *

Yes
No
I'm not sure

What type of refractive error do you have? *

Nearsightedness (myopia) -- you have trouble seeing distance
Farsightedness (hyperopia) -- you have trouble seeing up close
Reading (presbyopia) -- you have trouble seeing intermediate
I'm not sure

When was your last noticed vision change (date)? *

In the past 3 months, have you been pregnant/nursing/breastfeeding? *

Do you have any of the following conditions? *

Keratoconus or other corneal thinning disorder
Corneal scarring
Glaucoma
Cataracts
Ocular herpes diagnosed in past year
Diabetes
Immunocompromised for any reason
Collagen vascular disease
Autoimmune disease (for example, AIDS, lupus, rheumatoid arthritis, multiple sclerosis, or myasthenia gravis)
None of the above

My preferred method(s) of contact is:

By Phone
By Email
By Snail Mail

By submitting this form, I give Keil Lasik Vision Center consent to contact me at any phone numbers or emails I provide, including mobile phone numbers.
I understand that my consent is not a requirement of purchase from Keil Lasik Vision Center.

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