Please fill out then print this checklist, and bring it with you for your Consultation.

Without glasses or contact lenses…

Yes No
Do you have trouble seeing at distance?
Do you have trouble seeing up close?
Do you have night vision problems?
If yes, please describe:
Do you have dry eye problems?
If yes, please describe:
Have you noticed a change in your vision over the last year?
If yes, please describe:
Do you have severe diabetes or severe allergies?
Do you have any active eye diseases, for example glaucoma or macular degeneration?
Do you have collagen vascular, autoimmune or immunodeficiency diseases, such as Rheumatoid arthritis, Lupus or AIDS?
Do you show signs of keratoconus (corneal disease)?
Do you have Vision Insurance?If yes, please provide Front Desk with Benefits card so that we may make a copy.
Would you be satisfied if your natural vision was greatly improved even if you still had to wear corrective lenses some of the time?
Do your glasses or contacts interfere with your recreational activities?
If yes, which activities:
Is it acceptable to you that you may need glasses for reading after your Lens surgery?
Do you have vision problems with reading or computer work?
If yes, please describe:
Do you have vision issues, limitation, or restrictions with your work or profession?
If yes, please describe: