LASIK Self-Test Name* First Last Phone Number*Email* How's Your Vision Now?*Trouble seeing far awayTrouble seeing up closeI can't really see at allAge Range*Select One18 - 2930 - 3940 - 5455 - 6465+What do you currently wear to correct your vision?*Select OneGlassesContactsGlasses and ContactsReading Glasses OnlyI don't wear anything (but I should!)Have you been told you have Astigmatism?*Select OneYesNoHave You Been Diagnosed with Any of the Following*Select OneKeratoconusCataractsNeither of the above"I'm fed up with my glasses and contacts and want to make a change because..."*Select OneFoggy Glasses - They're a total pain!Screens - My eyes get tired/dry staring at screens with my contacts in.Active Lifestyle - I want run/ride/play and not fiddle with my glasses or contacts.Time - I'm tired of wasting time every morning and night with my contacts.Expense - I feel like I'm just "renting" good vision by paying for glasses/contacts year after year.Safety/Security - If I have to get up in the middle of the night, and I can't find my glasses, that's a scary situation.If you are a candidate for vision correction, how soon would you like to upgrade your vision?*Select OneAs soon as possibleIn the next few weeksIn the next few months Δ