Toronto Laser Eye Surgery correction & treatments, Toronto laser eye surgeon centre in Toronto Ontario

*Name:

*Email:

*Age:

Phone (home):

Phone (work):

Ext:

Why are you considering laser vision correction?

Tell us about your eyes:

*Has your prescription changed since last year?

Yes No Left eye Right eye

*Has your prescription changed since last year?

Yes No Don't Know

*How often do you wear your glasses?

Full-time Part-time Never

*How often do you wear your contact lenses?

Full-time Part-time Rarely Never

*Do you wear monovision contacts?

Yes Yes No

When did you last wear your contacts?

* Required