LASIK Self Evaluation Maryland | LASIK Test Frederick

	Offices in the Tri State Area - Frederick, Hagerstown, and Cumberland Maryland. Call (301) 745-5150
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	Self Evaluation Test The answers to your questions will be sent directly to our staff counselors who will contact you shortly to clarify any points that need more discussion and let you know if it appears as though LASIK will work for you. The only way to be certain whether LASIK can work for you is to complete the LASIK Evaluation which New Vision Laser Center will offer to you at no charge or obligation. Be sure to include a phone number and email address where we can contact you. Thank you for your interest in New Vision Laser Center and for submitting your answers to this Self Evaluation Test. 1. What is your age group? under 18 19-39 40-59 60+ Please select your Age 2. Without my glasses and contacts: (check all that apply) I have trouble reading and seeing things up close I have trouble driving and seeing things that are far away I’ve been told that I have astigmatism Please describe your vision. 3. What do you usually wear? (Check All that Apply) Glasses Contacts Reading Glasses Please select what you wear. 4. Do you have any of the following? Rheumatoid Arthritis Multiple Sclerosis Lupus Cataracts Keratoconus Ulcerative Colitis/Crohn's Disease Prior Eye Surgery Prior serious eye injury None of the above Required 5. Yes, I would like to schedule a FREE Exam or Consultation. The best time to call me is: ** 8am-12pm 12pm-4pm 4pm-7pm Please select when you would like to be contacted for your consultation 6. How would you describe your current LASIK thinking: I'm in the "learning about LASIK" mode. If I am a good candidate I am ready to have the procedure 7. Please provide us with your contact information: First Name:Required. Last Name:Required. Email Address:A Valid Email is Required. Phone Number: Area Prefix Suffix -- 8. Would you like to order your Free Educational DVD? Yes, Please mail my Free Educational DVD to the following address: Street Address: City: Required. State: Required. Zip Code: Required.


	Cash Rebate FREDERICK 176 Thomas Johnson Drive, Suite 100, Frederick, MD (301) 662-3937 HAGERSTOWN 1640 Dual Highway, Suite B, Hagerstown, MD 21740 (301) 745-5150 CUMBERLAND 2 Frederick Street, Cumberland, MD 21502 (301) 722-4000

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