LASIK Consultation Form - HAWAII VISION CLINIC

Please complete this form and a representative will contact you as soon as possible. Required fields are marked with an asterisk(*).

First Name: *

Last Name: *

Street Address:

Address (cont.):

City: *

State/Province: *

Zip/Postal Code: *

Island (Hawaii or Guam):

Country:

Cell *

Work Phone:

Email address *

Confirm email *

Date of Birth *

Your Sex:

Occupation (description): *

Are you Active Military, DOD or a Dependant:

What kind of correction do you normally wear: *

About how long have you worn glasses?

# of years

Are you Presbyopic (do you need bifocals or reading glasses)

If you have your prescription for glasses or contacts please complete this section bellow:

Indicate what type of RX this is:

Right Eye

(e.g.: -4.25 -1.00 x 160 +1.50) contact lens power is entered under Sphere only.

Sphere

Cylinder (astigmatism)

Axis (@)

(+) Add

Left Eye

Sphere

Cylinder (astigmatism)

Axis (@)

(+) Add

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Other comments

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