Laser Vision Consultation Form

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

Hawaii Vision Clinic, Inc

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

# of years

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

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

Left Eye
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