Am I a Candidate for LASIK?

Your Full Name*

Email*

Your Age*

Please Note

All patients 50 or over must first have a cataract evaluation with a cataract surgeon (this does not include yearly eye exams with an optometrist). We recommend contacting an ophthalmology office to schedule a cataract evaluation. Notify them you would like the results of the exam faxed to 616-365-5778 for review. Once you've scheduled your cats evaluation, please call to notify our office.

Birthdate*

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

Yes
No

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 Don't Know

Do You Have Astigmatism?*

Yes
No
I Don't Know

Vision Change?

Do You Have Any of the Following Conditions? (Please select all that apply)*

Keratoconus or other corneal thinning disorder
Corneal scarring
Glaucoma
Cataracts
Ocular herpes diagnosed in past year
Retinal disease
Dry eye
To the best of my knowledge, I have none of these conditions

Cataracts Notice

Unfortunately, cataract growth does disqualify you from the services we offer. We recommend contacting an ophthalmology office to schedule a cataract evaluation and continue monitoring them yearly. If you have any questions, please feel free to contact our office at 616-365-5775.

Do You Have Any of the Following Conditions?*

Diabetes
Autoimmune disease (for example, AIDS, lupus, rheumatoid arthritis, multiple sclerosis, or myasthenia gravis)
Immunocompromised for any reason
Collagen vascular disease
To the best of my knowledge, I have none of these conditions

Other Information

Comments

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Am I a Candidate for Lasik?

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