Name: Ms. Mrs. Mr. Dr.

Address 1:

Address 2:

City: State: Zip:

Phone: Fax:

Email:

Convenient time to contact you:

Please have a representative contact me to set up my FREE laser vision screening.

How long have you worn glasses? years
How long have you worn contact lenses? years

I normally wear (check one) Glasses Contact lenses (check type) soft soft toric hard

My need for glasses or contacts is for Distance vision only
Reading vision only Both

Have you had any significant changes in your vision during this past year? Yes No

Are you experiencing dry eyes? Yes No
Are you experiencing watery eyes? Yes No

How did you hear about us? (Please check all that apply)
TV-Ch. 3 TV-Ch. 6
KFTX Radio KRYS Radio KZFM Radio
Caller Times Other Newspaper
Direct Mail Flyer Internet
Seminar at
Brochure Poster On-Hold Message Eye Doctor/staff
Primary Care Doctor
Friend/Family

What questions or concerns do you have about laser vision correction?

Thank You.