This is a preliminary evaluation to see if you are, or are not, a candidate for laser eye surgery.
Excimer Laser Eye Surgery - Evaluation Form - (PLEASE ANSWER ALL QUESTIONS IF POSSIBLE)

ExamThis 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:
Email (required):
Phone No. (with area code):
Fax No. (with area code):
Mailing address:
City / State / or prov. / county:
Postal or Zip code:
Date of birth:
Age:

Type the disorder you have: Myopia (nearsightedness or shortsightedness), Hyperopia (farsightedness), Presbyopia, Astigmatism.

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

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

At this time we do not operate on, Keratoconus. AND NOW WE DO PRESBYOPIC SURGERY, (need for reading eyeglasses).

Sex: Male, Female. Type of work: . If you have any other eye disorders or disease, please specify:

Thank you, we will be contacting you shortly.
Exam

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E-mail: laser@eyesurgeries.com
Cirugia Ocular y Laser, P.O. Box 1104-1007, San Jose - Costa Rica.
Telephones: (506) 2291-0231 / (506) 2232-8420 - Tel. / Fax: (506) 2231-7342
All contents copyright © 2000 - 2003, Cirugía Ocular y Láser All rights reserved.
Revised: August 18, 2010