*Your Name

*Your Phone Number

*Your e-mail address

Does sun glare or headlight glare make driving difficult for you?
Yes       No

We now have contact lenses for nearsightedness, astigmatism, farsightedness, and for bifocal wearers too! Would you be interested in trying contact lenses for a day at no charge?
Yes       No

Laser vision correction can eliminate the need for glasses or contact lenses in people with nearsightedness, astigmatism, or farsightedness. Would you like to know more about this freedom from glasses and contacts lenses?
Yes       No

Do you find it difficult or uncomfortable to read?
Yes       No

How many days a week do you use a computer for at least an hour a day?
None      1      2      3      4      5      6      7

Please list your employer

Your occupation

First visit? Who can we thank for recommending us?

Do you participate in any of the activities listed below? (Please check any that apply. )
Boating/Fishing     Golf     Basketball     Baseball
Hunting/Gunning     Soccer     Beach Activities     Football
Needlecrafts     Handcrafts     Other

Name and telephone number of your family doctor

Name and telephone number of an emergency contact person