LASIK Survey

LASIK Eye Surgery Price

Is LASIK right for you?  Fill out the survey below and someone on our LASIK at Southern Eye team will contact you to discuss your results during our regular business hours M-F 8 AM-5 PM

Pregnant or nursing within the past 6 months? (required)

Planning a pregnancy within the next 6 months? (required)

Do you have lupus? (required)

HIV? (required)

Do you have any form of Arthritis? (required)

Are you Diabetic? (required)

History of seizures, or medication for seizures? (required)

Ever had a herpetic eye infection or shingles on the face? (required)

Allergic to Latex? (required)

Allergic to Betadine? (required)

Taking Coumadin or another blood thinner? (required)

Taking any diet meds or anything with phentermine? (required)

Are you taking prescription Migraine Medication? (required)

Ever had corneal erosion problems? (required)

Do you weigh under 300 lbs? (required)

Have you every had any type of eye surgery? (required)

Any Auto-immune Disorder/Disease i.e. (Gastro, Thyroid, Fibromyalgia, MS...) (required)

Have you ever experienced keloids or hypertrophic scarring? (required)
YesNo
Do you wear contacts? (required)
Name of your Optometrist?