1a. Please state the visual acuity of Left eye. *

1b. Please state the visual acuity of Right eye *

2. Without your glasses/contact lenses do you have trouble seeing *

3. Do you wear? *

What sort of contacts do you wear?

What type of soft disposable contacts?

Do you sleep in your contact lenses overnight?

What is your prescriptions?

4. Has your prescription changed in the last 2 years? *

5. When are you thinking of having the laser eye surgery procedure?

6a. What is your age? *

6b. What age did you start wearing glasses or contact lenses?

7. Do you participate in any of the following?

8. Do you wear spectacles or contact lenses when doing the following? *

9. Do you have any of the following eye conditions? *

10. Do you have any allergies to medications? *

11. Does anyone in your family have any of the following conditions? *

12. What is your main reason for seeking LASIK? *

13. Do you know anyone who has laser vision correction? *

Was it at the Maja Clinic?

Were you given a recommendation to a particular doctor?

14. How did you hear about us? *

Your Name *

Email Address *

Phone Number *

Preferred method of contact *

Postcode *

Gender *