Are You A LASIK Candidate?

LASIK is life changing. It can provide you with the freedom to wake up each day, jump out of bed and see the world clearly without fumbling for your glasses or putting in contact lenses. LASIK has already transformed the lives of millions of people just like YOU. But the question remains: is it right for YOUR EYES?

Take a quick second, and fill out as much information as you know about your eyesight and general health. The answers to these questions will give us a very accurate prediction of your candidacy for LASIK, and what visual results you can expect.


Your Age
Do you Suffer From (check all that apply)
Nearsightedness
Farsightedness
Astigmatism
Do you know your prescription?
+5 to 0
0 to -5
-5 to -10
-10 or higher
I don’t know
Has your prescription been stable for the last year?
Yes
No
I don’t know
Do you have trouble seeing distance or near without corrective lenses?
Distance Only
Near Only
Both
What typer of eyewear do you use now? (check all that apply)
Eyeglasses Only
Soft Contact Lenses Only
Both Eyeglasses and Soft Contact Lenses
Soft Toric Contact Lenses
Gas Permeable Rigid Contact Lenses
None of the Above
Do you wear reading glasses or bifocals?
Yes, Reading Glasses
Yes, Bifocals
No
How would you rate your quality of night vision?
Good Night Vision
Fair Night Vision
Poor Night Vision
Do you have any of the following conditions? (check all that apply)
Rheumatoid Arthritis
Keratoconus
Cataracts
Currently Pregnant
None of the Above
Have you ever had an eye injury or eye surgery?
Yes
No
What is your main expectation from having LASIK?
Lifestyle Improvement (sports, appearance)
Tired of glasses/contacts
General better vision
What has kept you from having LASIK in the past?
How did you hear about us?
Please provide us with your contact information and we will e-mail you your detailed results.
The answers to these questions will give us a general guideline as to your candidacy and expected outcome, the results of which we will provide. However, this short questionnaire is NOT a substitute for a proper medical examination and is simply a guide to help you work out if LASIK should be on your ‘to do’ list. The only way to know if LASIK is right for your eyes is to have a thorough LASIK Medical Examination.
Name *
First Last
Email where the results will be sent: *

Cell Phone Number *

We will contact you via email with the results.
If you are a candidate would you like us to contact you to schedule your free consultation?

Did You Know...

Dr. George Simon is among the most experienced LASIK surgeons in all of Northern California? Combined with Dr. Abrams, the two have performed over 100,000 LASIK procedures!