Diagnostic Eye Center - LASIK Self Test

First Name*
Last Name*
Phone Number*
Email*
Phone Validation
Oops! It looks like the phone number you input is invalid. Please input a valid phone number in order to submit.

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

Farsightedness: I have trouble reading and seeing things up closeNearsightedness: I have trouble driving and seeing things far awayAstigmatism: I have distorted vision and cannot see very well

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

GlassesContactsReading GlassesNone of Them

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

12345
Rate this statement on a scale of 1 to 5 with 1 being the lowest.

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

12345
Rate this statement on a scale of 1 to 5 with 1 being the lowest.

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

YesNo
Newsletter

Yes, subscribe me to this newsletter.
I agree to the Terms of Use. By submitting this form you consent to receive phone calls, text messages and emails related to scheduling your appointment and related promotional offers from Diagnostic Eye Center. It is not a condition of purchasing any goods or services. You can opt out at any time, message/data rates may apply, message frequency may vary, and opting-in includes acceptance of the Privacy Policy. and Terms of Use. Communications through this website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.
By submitting this form you consent to receive phone calls, text messages and emails related to scheduling your appointment and related promotional offers from Diagnostic Eye Center. It is not a condition of purchasing any goods or services. You can opt out at any time, message/data rates may apply, message frequency may vary, and opting-in includes acceptance of the Privacy Policy. and Terms of Use. Communications through this website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.
Should be Empty: