Welcome To Your Free LASIK Evaluation To Determine Candidacy 1 2 3 4 5 6 7 8 First Name*Last Name*Email* Phone* By submitting this form, I give The LASIK Vision Institute® (LVI) consent to contact me at any phone numbers I provide to LVI, including mobile numbers, via an automatic telephone dialing system in regard to my request for information on LVI services and treatment information. I understand that my consent is not a requirement of purchase from LVI. What is Your Age Group?*Under 1818-4041-5960+ Do you have trouble seeing up close, far away or both?*(Check all that apply) I have trouble seeing up close I have trouble seeing things far away I have trouble seeing BOTH up close and far away Do you wear any of the following?*(Check all that apply) Glasses Contacts Both Do you have any of the following?*(Check all that apply) Astigmatism Cataracts Keratoconus Diabetes Prior Eye Injury or Eye Surgery Am currently pregnant None of the above How important is being able to enjoy living and working without glasses or contacts to you?*(Check all that apply) It's very important to me NOT to wear glasses for outdoor activities. It's very important to me NOT to wear glasses for work purposes. Not very important. I do not mind wearing glasses or contacts. When choosing a vision correction surgeon, which matters most to you?*(Check all that apply) Affordability Safety Convenience Experience of the Doctor Other Other: How did you hear about us?* Radio TV Google Search Family/Friend Facebook Other NameThis field is for validation purposes and should be left unchanged.