Free consult - CS LASIK Institute

Note: Consultations are 1hr 45min and eyes will be dilated

Name

First

Last

Date of Birth mm/dd/yyyy

Phone

Email Address

Zip code

How did you hear about CS LASIK Institute?

If referred by a patient, staff member, or doctor; please specify their name:

Please select your age range

You are currently not eligible for laser vision correction.

Please call the office to schedule 719-258-1260

(Female patients only) Are you currently pregnant?

Yes

You are currently not eligible for laser vision correction.

(Female patients only) Are you currently nursing?

Yes

You are currently not eligible for laser vision correction.

(Female patients only) Do you have an infant less than 3 months old?

Yes

You are currently not eligible for laser vision correction.

I primarily correct my vision with

Glasses

Contact lenses

I currently do not wear any type of correction

If you wear contact lenses, you will be required to remove them 3-7 days prior to your consultation. Do you have glasses to wear when unable to wear your contacts?

Yes

What type of glasses do you wear?

Distance only

Bifocals, trifocals, or progressives

Reading glasses only

I am unsure what type of glasses I wear

Please select what type of contact lenses you wear

Soft

Hard or gas permeable

Do you sleep overnight in your contact lenses?

Yes

You are REQUIRED to remove your contact lenses for a full 7 days prior to your consultation. Contact lenses reshape your cornea, and removal is required for accuracy. You will need to wear glasses instead during this time.

Does either contact lens box say “Toric” or “For Astigmatism”?

Yes

You are REQUIRED to remove your contact lenses for a full 5 days prior to your consultation. Contact lenses reshape your cornea, and removal is required for accuracy. You will need to wear glasses instead during this time.

You are REQUIRED to remove your contact lenses for a full 3 days prior to your consultation. Contact lenses reshape your cornea, and removal is required for accuracy. You will need to wear glasses instead during this time.

Please call the office to schedule 719-258-1260

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