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LASIK Candidacy Test

In order to better understand if you would be a good candidate for LASIK laser vision correction please take a moment to complete the form below. Once your visual needs and lifestyle requirements have been determined it will be easier for our LASIK coordinator to answer any of your questions relating to LASIK in Canton or any other vision correction procedure that might be applicable (Highly nearsighted (myopic) patients should see the Implantable Collamer Lens section of our website. (also known as the Implantable Contact Lens or Visian ICL) .

First Name:
Last Name:
Phone:
Address:
City:
State:
Are you willing to discuss with lasik coordinator:
Best time to call:
E-Mail:
Are you at least 21 years old?	Yes No
Do You Require Glasses or Contacts to Drive?	Yes No

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

Maybe
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

If you are interested in laser eye surgery, please fill out the form below to schedule an appointment with Dr. Todd Fladen or click the button below to get an immediate call back from us.