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Hampton
1613 Hardy Cash Drive
Hampton, VA 23666
Williamsburg
5215 Monticello Ave
Williamsburg, VA 23188
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757-229-4000
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LASIK
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LASIK Self-Test
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Name
Phone
Email
Do you have trouble seeing far away or up close?
Select Your Answer
Up Close
Far Away
2. How interested are you in being able to play sports without glasses and contacts?
Select Your Answer
It is very important to me NOT to wear glasses for activities such as sports.
It is not important to me. I do not mind wearing glasses.
3. What is your age?
Select Your Answer
Under 21
21-40
40-69
69+
4. Are you interested in seeing well up close (reading) without glasses?
Select Your Answer
It is very important to me NOT to wear reading glasses.
It is not important to me. I do not mind wearing reading glasses to see things up close.
5. Do you wear contact lenses or glasses?
Select Your Answer
Glasses
Contact lenses
6. Would your career or business activities improve if you were to become less dependent on glasses and contacts?
Select Your Answer
Yes
No
Maybe
7. Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?
Select Your Answer
Yes
No
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+
LASIK
LASIK Eye Surgery
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