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303-794-1111
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Preferred Date
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Are you a current patient?
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Yes
No
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Date of Birth
Preferred Location
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InSight Parker
InSight Denver - Lowry
InSight Denver - Yale
InSight Boulder
InSight Longmont
InSight Arvada
InSight LASIK South
InSight LASIK North
I currently wear (check as many that apply)
Soft Contacts
Gas Permeable Contacts
Glasses
Readers
I am
Nearsighted
Farsighted
Astigmatic
Please describe the nature of your appointment (e.g., consultation, check-up, etc)
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LASIK Candidacy Survey
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Please complete the following questions to help us provide you with an appropriate response.
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Who is your current eye doctor?
Date of Birth
Which location would you prefer?
*
LASIK Parker Office
LASIK Boulder Office
I wear glasses and contacts because (check all that apply)
I have trouble reading and seeing things up close
I have trouble driving and seeing things far away
I have astigmatism
What do you usually wear (check all that apply)
Glasses
Contacts
Reading Glasses
I don't wear correction and probably should
Have you ever had (check all that apply)
Previous Eye Surgery
A serious eye injury
Cataracts
Keratoconus
Diabetic Retinopathy
Where do you live your visual life (check all that apply)
I love the outdoors and am active
I love reading
I love participating in sports
I spend hours on my computer
What are your expectations after LASIK? (check all that apply)
I am fine wearing glasses for distance
I do not want to wear glasses for distance
I am fine wearing glasses for up close and reading
I do not want to wear glasses for seeing up close
Would you be willing to review your level of candidacy with one of our InSight LASIK Counselors?
*
Yes
No
Submit