FREE LASIK Evaluation Thank you for your interest in LASIK, with Beach Eye Care! Please take a moment to fill out the evaluation form below, so that we can better understand your needs. Step 1 of 3 33% Name(Required) First Last Email(Required) Phone (preferred)What is your age? Do you wear contacts or glasses?(Required)-- Select One --ContactsGlassesBothNo, I don't have contacts or glassesAre your glasses for reading up close? Yes No Can you tell us your most recent prescription? Yes No Left Eye Prescription Right Eye Prescription Have you ever had eye surgery? Yes No What is the most important issue for you regarding LASIK?-- Select One ---AffordabilitySafetyExperience of doctorBeing free of my glasses or contactsWhen are you considering LASIK?-- Select One --NowIn the near futureNext yearWhat bothers you the most about having to wear glasses or contacts? Would you like to schedule your FREE evaluation?(Required) Yes No How would you like to be contacted? Email Phone How did you hear about Beach Eye Care LASIK?Check all that apply. VSP Other Insurance Internet Search Another Doctor A Beach Eye Care Employee Friend or Family Member Social Media Radio Advertisement In the Community Other Other YOUR EVALUATION APPOINTMENTPlease note: The location for all LASIK evaluations is the Hill Top (First Colonial Rd) location.Appointment PreferenceFirst AvailableSelect a preferred date and timeWe'll do our best to accommodate your appointment preference.Preferred day of the week-- Select One --MondayTuesdayWednesdayThursdayFridayPreferred Time Hours : Minutes AM PM AM/PM Disclaimer(Required) I have read and understand the disclaimer. I am 18 years of age and have had a stable glasses or contact lens prescription for at least two years. Have sufficient corneal thickness (the cornea is the transparent part of the eye). A LASIK patient should have a cornea that is thick enough to allow the surgeon to safely create a clean corneal flap of appropriate depth. Are affected by one of the common types of vision problems or refractive error - myopia (nearsightedness), astigmatism (blurred vision caused by an irregular shaped cornea), hyperopia (farsightedness), or a combination thereof (e.g. myopia with astigmatism). Several lasers are now approved by the U.S. Food and Drug Administration (FDA) as safe and effective for use in LASIK, but the scope of each laser’s approved indication and treatment range is limited to specified degrees of refractive error. Do not suffer from any disease, vision-related or otherwise that may reduce the effectiveness of the surgery or the patient’s ability to heal properly and quickly. Are adequately informed about the benefits and risks of the procedure. Candidates should thoroughly discuss the procedure with their physicians and understand that, for most people, the goal of refractive surgery should be the reduction of dependency on glasses and contact lenses, not their complete elimination. NameThis field is for validation purposes and should be left unchanged.