Dr. Joe Weinstock - Lasik Laser Eye Surgery

Am I a Candidate for Laser Surgery?

Please complete the information below, to see if laser surgery would be to your benefit. You may leave lines or spaces blank if you do not have the information.

* = REQUIRED FIELDS

We will get back to you within 48 hours.

Salutation:
*First Name:
*Last Name:
*E-Mail Address:
*Address:
*City:
*Province:
*Postal Code:
*Home Phone:
Evening Phone:
Gender:
Corrective device you are using:
Contact lens type:
Duration of eyewear usage:	years
Do you have presbyopia (reading glasses):
Your age:	years old

Optional Information:

Present glasses prescription: (be sure to put +/-)
Date:
Right eye: sphere cylinder axis
Left eye: sphere cylinder axis

Present contact lens prescription:
Brand of contact lens:
Type: Hard or Soft
Prescription: (be sure to put +/-)
Right eye: sphere cylinder axis
Left eye: sphere cylinder axis

Any history of eye disease?
Cataract
Glaucoma
Corneal ulcer
Eye turns
Eye surgery
Other