Eye Care, MD of New Jersey, P.A.

WelcomeEye Health UpdateLaser Vision CorrectionMap & DirectionsPatient Contact
Patient Contact
Laser Vision Correction Inquiry
Name:
Address:
City:
State:
Zip:
Daytime Phone:
Email:
Age: Male Female
   
Contact Lens Prescription
(if available):

Soft Lenses
Gas Permeable

Right Eye:
Left Eye:
   
Glasses Prescription
(if available):
Right Eye:
Left Eye:
   
Are you interested in
(check all that apply):
Attending a free seminar?
Scheduling a complimentary consultation?
Having information mailed to your home address?
Applying for financing?
   
How much do you know about LASIK?
I just started my research.
I've been researching for at least one year.
I know someone who had it done.
Other:
   
You are considering Laser Vision Correction because:
Inability to wear contact lenses.
Discomfort and appearance of glasses.
Inability to enjoy water sports.
Career choice requires good vision.
Other:
   
What would prevent you from getting Laser Vision Correction:
Financing situation.
Need more time to research.
Fear of pain.
Other:
 
Other Comments:

 

Welcome • Eye Health Update • Laser Vision Correction • Map & Directions • Patient Contact

Privacy Policy

Programming and Design by Mojo Interactive & ISRS Interactive, 2003.
Copyright © 2003 EYECARE, MD of New Jersey, All rights reserved.