Evaluation Form

Thousands of successful surgeries with Excimer Laser using the Lasik technic. Correct myopia, hyperopia and astigmatism. Pioneers in Costa Rica.

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Excimer Laser Eye Surgery - Evaluation Form

This is a preliminary evaluation to see if you are or are not a candidate for laser eye surgery. Please answer the questions to the best of your knowledge. If you do not receive a conformation message after pressing the "Submit this form" button, please send the information by regular E-mail: laser@eyesurgeries.com You may also print out and fax this form to: (506) 2231-7342.

Name *

E-mail *

Phone No. (w/ area code)

Fax No. (w/ area code)

Mailing address

City / state or prov. / country

Postal or Zip code

Date of birth

Age

Graduation of glasses or contact lenses that you are using at this time (each eye separately) Right eye.

Graduation of glasses or contact lenses that you are using at this time (each eye separately) Left eye.

Sex

Type of disorder you have

Visual acuity measurement, using the Schnellen chart measurement. (You could get this with an optician), example: 20/20. Right eye.

Visual acuity measurement, using the Schnellen chart measurement. (You could get this with an optician), example: 20/20. Left eye.

If you have any other eye disorder or disease, please specify.

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Excimer Laser Eye Surgery - Evaluation Form