Take Our LASIK Quiz to See if You Qualify! Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.First Name *Phone Number *What is your Age? *Under 2121-4041-6970+Are you interested in seeing well up close (ex. reading) without glasses? *It's very important to me NOT to wear reading glasses.It is NOT important to me. I don't mind wearing reading glasses to see things up close.Do you know your visual prescription? *YesNoDo you have dry eyes?YesNo (ex. results. you Email *Do you have trouble seeing far away or up close? *Up CloseFar AwayUp Close and Far AwayWhat is your current method of vision correction? *GlassesContact LensesContact Lenses and GlassesHas your prescription been stable over the past two years? *YesNoDo you have any autoimmune diseases, collagen vascular diseases, diabetes, or are immunocompromised?? *YesNoDo you have corneal thinning (keratoconus), corneal scarring, glaucoma, cataracts, herpetic eye disease, or retinal disease? *YesNoA surgical consultant from Little Rock Eye Clinic will contact you with your results. Would you prefer we reach you by phone or email? *PhoneEmailHow did you First hear about us? *GoogleFacebookTVNews ArticleFriend or Family MemberOtherConsent to Submit Information *I agree to the below statement.By checking this box, I acknowledge that I am voluntarily submitting personal health information, including details about my eyes, and I consent to its collection and secure transmission. I understand that this form is intended for informational purposes only and does not establish a provider-patient relationship.Submit
