TESTFind out if you are a good candidate for laser vision correction

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Answering these questions will help us determine if you are a good candidate for laser correction.

After completing the LASIK test, we will offer you a special offer for a
laser vision correction examination for only €45 instead of €100!

Gender*

Gender*

How old are you?*

How old are you?*

You have trouble seeing: **

You have trouble seeing: **

Do you have astigmatism? **

Do you have astigmatism? **

You wear: **

You wear: **

Has your diopter changed in the past year? **

Has your diopter changed in the past year? **

Do you have any of these eye diseases? **

Do you have any of these eye diseases? **

Do you have any of these systemic illnesses?*

Do you have any of these systemic illnesses?*

Are you pregnant? **

Are you pregnant? **

Do you breastfeed? **

Do you breastfeed? **

What is the main reason why you want the laser vision correction? **

What is the main reason why you want the laser vision correction? **

How did you find out about us?*

How did you find out about us?*

Name and surname:*

Name and surname:*

Please enter your first and last name!

Date of birth:*

Date of birth:*

Please enter your date and year of birth!

Phone:*

Phone:*

Please enter your phone number!

Address:

Address:

Please enter your Address!

E-mail:*

E-mail:*

Please enter your e-mail address!

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