Refer A Patient

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    Personal Information

    Patient Referral Information

    Medical Documentation

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    Only .jpg .png & .pdf files can be uploaded

    Additional Information

    Free-LASIK Self-Test

    Take the first step towards visual freedom. Our expert team will conduct a thorough evaluation to determine your candidacy for laser vision correction and recommend the most suitable procedure for your unique eyes.

    What is your age group?

    Without my glasses and contacts... (Check All That Apply)

    What do you usually wear? (Check All That Apply)

    Do you have any of the following? (Check All That Apply)

    I would like to see well at a distance without relying on glasses and contact lenses. (Rate this statement on a scale of 1 to 5 with 1 being the lowest.)

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    I would like to see well up close without relying on glasses and contact lenses. (Rate this statement on a scale of 1 to 5 with 1 being the lowest.)

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    Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?

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