Questionnaire

How Old Are You?(Required)

Under 18

19-39

40-55

56+

You may not be a candidate for RLE surgery but Dr. Hamilton can further evaluate your situation. Our office will reach out to take your insurance information and schedule a medical consultation

Have you ever been told you have Astigmatism?(Required)

Yes

No

What do you have to wear glasses/contacts for?(Required)

Driving

Computer

Reading

All of the above

Have you had any of the following procedures on your eyes (LASIK, SMILE, PRK, RK, Cataract surgery)?(Required)

Yes

No

Have you had previous eye surgery such as cataract, glaucoma or retina surgery?(Required)

Yes

No

Have you been told you have cataracts, diabetic retinopathy, macular degeneration or other vision limiting eye condition?(Required)

Yes

No

You may not be a candidate for RLE surgery but Dr. Hamilton can further evaluate your situation. Our office will reach out to take your insurance information and schedule a medical consultation

Name(Required)

First Last

Email

Phone