LASIK Candidacy Test - Hamilton Eye

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LASIK Candidacy Testdrhadmin2019-05-31T17:10:56+00:00

LASIK Candidate Survey

Step 1 of 9

11%

First Name*
Last Name*
Email*
Phone*

What is your age?*
- Under 18
- 19-39
- 40-59
- 60+

Without my glasses and contacts...*
- I have trouble reading and seeing things up close
- I have trouble driving and seeing things far away
- I have been told that I have astigmatism

What do you usually wear?*
- Glasses
- Contacts
- Reading Glasses

Do you have any of the following?*
- Cataracts
- Keratoconus
- Diabetic Retinopathy
- Prior Eye Surgery
- Prior serious eye injury
- I am currently pregnant
- None of the above

How interested are you in being able to enjoy outdoor activities and/or sports without glasses and contacts?*
- It's very important to me NOT to wear glasses for outdoor activities and/or sports
- It's not important to me. I do not mind wearing glasses

Are you interested in seeing well up close (reading) without glasses?*
- It's very important to me NOT to wear reading glasses
- It's not important to me. I do not mind wearing reading glasses to see things up

Would your career or business activities improve if you were to become less dependent on glasses and contacts?*
- Yes
- No
- Maybe

Would you be willing to discuss this procedure and your candidacy with our coordinator?*
- Yes
- No
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Spring Break Special 20% off SMILE, LASIK or EVO (March Only)

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IMPORTANT COVID-19 UPDATE

Given the recommendations from the American Academy of Ophthalmology regarding the ability to conserve personal protective equipment by delaying elective surgery and support the incredible healthcare workers caring for COVID-19 patients, Dr. Hamilton is temporarily suspending elective eye surgery including cataract and refractive (e.g. LASIK/SMILE) surgeries.

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Name*
First Last
Email*
Preferred Phone Number*
Reason for Appointment?*
How you found us?*
Date Available On Or After*
MM slash DD slash YYYY
Preferred Day(s) of the Week*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Preferred Time of Day*
- AM
- PM
Age Group*
- 19-39
- 40+
Have You Had Previous Eye Surgery?*
- I have NOT had previous eye surgery
- I have had previous eye surgery
Are You Pregnant or Currently Nursing?*
- No
- Yes
Comments or Questions:
Please enter four p l u s 7*
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