Laser Vision Consultation Form - HAWAII VISION CLINIC

CONTACT

1330 Ala Moana Boulevard
Suite 10
Honolulu, Hawaii 96814
P: (808) 594-9194
F: (808) 941-8646

Hawaii Vision Clinic, Inc

Name(Required)

Email(Required)

Enter Email Confirm Email

Address

Street Address City Island (Hawaii or Guam): ZIP / Postal Code

Phone(Required)

Work Phone

Birthday

Gender

Occupation (description):(Required)

Are you Active Military, DOD or a Dependant:

What kind of correction do you normally wear:(Required)

About how long have you worn glasses?

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:

If you have your prescription please complete this section bellow:

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

Sphere

Cylinder (astigmatism)

Axis (@)

If you have your prescription please complete this section bellow:

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

Sphere

Cylinder (astigmatism)

Axis (@)

(+) Add

To serve you better let us know how you heard about us:

If you have a Groupon/Living Social please enter your coupon #:

IE: 0000-0000. You must print your voucher to find the barcode

Have you seen any other advertisements:

(Please tell us where i.e.: Honolulu Advertiser, Star Bulletin, Mid week, a Military paper, TV or Radio...)

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If you have any questions, please call our Honolulu office at (808) 594-9194 or email us at info@panpacificlaser.com.

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