Cirugia Ocular y Laser - Excimer laser eye surgery - Evaluation

This is a preliminary evaluation to see if you are, or are not, a candidate for laser eye surgery.

Excimer Laser Eye Surgery - Evaluation Form - (PLEASE ANSWER ALL QUESTIONS IF POSSIBLE.)

-Evaluation- This is a preliminary evaluation to see if you are or are not a candidate for laser eye surgery. Please answer the questions to the best of your knowledge. If you do not receive a conformation message after pressing the "Submit this form" button, please send the information by regular E-mail: laser@eyesurgeries.com

You may also print out and fax this form to: (506) 2231-7342.

Name:

E-mail (required):

Phone No. (w/ area code):

Fax No. (w/ area code):

Mailing address:

City / state or prov. / country:

Postal or Zip code:

Date of birth:

Age:

Type of disorder you have: Myopia (nearsightedness or shortsightedness), Hyperopia (farsightedness), Presbyopia, Astigmatism. Graduation of glasses or contact lenses that you are using at this time (each eye separately) Right eye:, Left eye:. Visual acuity measurement, using the Schnellen chart measurement. (You could get this with an optician), example: 20/20. Right eye:, Left eye:. At this time we do not operate on, keratoconus. AND NOW WE DO PRESBYOPIC SURGERY, (need for reading eyeglasses). Sex: Male, Female. Type of work:
If you have any other eye disorder or disease, please specify:

Thank you, we will be contacting you shortly.

-Examination-

E-mail: laser@eyesurgeries.com
Cirugia Ocular y Laser, P.O. Box 1104-1007, San Jose - Costa Rica.
Telephones: (506) 2291-0231 / (506) 2232-8420 - Tel. / Fax: (506) 2231-7342
All contents copyright © 2000 - 2003, Cirugía Ocular y Láser All rights reserved.
Revised: May. 3, 2008

Name:
E-mail (required):
Phone No. (w/ area code):
Fax No. (w/ area code):
Mailing address:
City / state or prov. / country:
Postal or Zip code:
Date of birth:
Age: