Request More Information

Prefix:
First Name*:    
Last Name*:    
City*:


Choose the State or Province in which you reside (choose "other" if you reside outside the US or Canada):

Do you currently wear either:  glasses       contacts      both

The following information will help us assess your suitability for laser eye surgery. The final decision is based upon the results of the Pre-Operative Eye Examination.

Please provide your current contact / glasses prescription for your:

left eye:
right eye:

What is your date of birth?
Date Day Month Year
(dd/mm/yyyy)


What is your current occupation?


May we contact your current eye doctor?

Yes
No


If yes, what is your current eye doctor's name?  

What is your current eye doctor's contact information?
Telephone (please include area code):

Eye Doctor's Address:

Street    
City    
Province/State    
Country    

Do you know any person who has had surgery at LASIK Eye Centres?
If so, please enter their full name:  
 
City:

Further comments/questions?
  

How did you first hear about Lasik Eye Centres?

Referral by former LASIK Eye Centre patient
TV Ad
Radio Ad
Newspaper Ad
Search Engine:
   (please specify)
Referral by Eye Doctor
Other    (please specify)

Please provide the following information so that we can contact you. We are able to reply to you if you fill in the telephone and email fields below. Information will only be used by LASIK Eye Centres.

Telephone*: (please include area code):
   

E-mail Address*: