New LASIK Patient Form Please fill out form below. If you are human, leave this field blank. Patient Name: *Today's Date:Sex:MaleFemaleDate of birth: *Age:Home Address:Home Phone:Work Phone:Mobile Phone:Employer:Work Address:Occupation:SS#E-Mail Address:Incase of emergency, who should be notified:Relationship to patient:Phone:Primary type of corrective lens wear:GlassesContact LensesBothNoneType of glasses worn:Single VisionProgressive BifocalStandard BifocalTrifocalYears of glasses:Years12345678910111213141516171819202122232425262728293031Months of glasses:Months123456789101112Dissatisfied with glasses because:Type of contact lenses worn:SoftHardGas PermeableToricsYears of contacts lenses:Years12345678910111213141516171819202122232425262728293031Months of contact lenses:Months123456789101112 Please select any of the conditions below you have had, or are currently being treated for: General Health:DiabetesHerpes/Cold SoresHIV+/Autoimmune DisorderLupusPacemakerRheumatoid ArthritisMedications:Allergies:Women: If Pregnant, How long? Breast feeding? (yes/no)Your hobbies:On a scale of 1 - 10, how interested are you in having your vision corrected? (1- not interested 10- ready to improve vision)How soon would you like to have your vision corrected?Check payment options:Check or CashCredit CardI would like to apply for financingHow did you hear about us?KFRGInternetTriCounty EyeYellow PagesOther:RelativeFriendCo - workerCurrent or previous Lasik patientIf current or previous Lasik patient, who was the patient?Captcha *reCAPTCHA is required.Send Form LASIK LINE 951-737-6402 Request an Appointment First Name * Last Name * Email * Phone Appointment Request – Extra Information Submit
