Self-Evaluation Test

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LASIK Eye Surgery Self Evaluation TEST

Name:
Phone:
E-Mail:
Address
City
State
Zip

Do you have trouble seeing far away or up close?
Up close

Far away
How interested are you in being able to play sports without glasses and contacts?
It's very important to me NOT to wear glasses for activities such as sports

It's not important to me. I do not mind wearing glasses
What is your age?
Under 21

21-40

40-69

69 +
Are you interested in seeing well up close (reading) without glasses?
It's very important to me NOT to wear reading glasses.

It's not important to me. I do not mind wearing reading glasses to see things up close.
Do you wear contact lenses or glasses?
Glasses

Contact lenses
Would your career or business activities improve if you were to become less dependent on glasses and contacts?
Yes

No

Not Sure
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.

Yes

No

Rosin Eyecare has convenient locations throughout the Chicagoland area. To speak with our LASIK Coordinator or to schedule a free, comprehensive LASIK consultation please call (800) 499-ROSIN, or e-mail us at jjacobson@rosineyecare.com.

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