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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:
What is your date of birth?
What is your current occupation?
May we contact your current eye doctor?
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:
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?
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*:
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