Schedule Your FREE Refractive Surgery Consult

1. General Information
2. First Name(required)
3. Last Name(required)
4. Email(valid email required)
5. Mobile Number
6. Home Number
7. Best Time To Call Morning Afternoon Evening
8. Date of Birth (Must be over 18 y/o)
9. Information Pertaining to Refractive Surgery
10. What procedure are you interested in? LASIK PRK LASIK/PRK VISIAN ICL/ INTACS
11. How soon are you considering having this procedure? Immediately 1 month 3 months 6 months
12. How did you find us?
13. How did you hear about our practice? Choose one... Washington Capitals Optometrist Physician Friends/ Family HOT 99.5 630 WMAL Web Search EDOW Staff Member Yellow Pages Washingtonian Magazine Yelp All About Vision Website (required)
14. Other Information
15. Do you wear Contact Lens? If so, then please answer the following:
16. Contact Lens Type Soft Toric Rigid Gas Permeable Hybrid Do Not Know
17. Frequency of use
18. Have you had any past Ocular Surgeries? If yes, then please list:
19. Do you have any allergies? If yes, then please list
20. Have you ever participated in a refractive surgery consultation? Yes No
21. Have you ever been told that you were not a candidate for Refractive Surgery? Yes No
22. Additional Comments
23. Comments
24. Please type in the verification code
25. 

 

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