LASIK Questionnaire | Sutton Linder Sutton | Lincoln, NE

402.484.0900

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Our Surgeons
LASIK
Cataracts
Patient Information
- Patient Forms
- Links
Contact
- Blog
- Careers
Virtual Consults

LASIK Questionnaire

What is your age range?*
- 21-29
- 30-39
- 40-54
- 55+
I most often wear:*
- Glasses
- Contacts
- Bifocals
- Readers
Without my glasses & contacts (check all that apply)*
- I have trouble reading and seeing things up close
- I have trouble seeing things from far away
- I have been told that I have astigmatism
How do you use your eyes on a daily basis outside of work? (check all that apply)*
- Reading
- Outdoor activities
- Sports / Fitness
- Scrapbooking/Sewing/Crafts
- Computer / Screen Time
- Other
Describe how do you use your eyes on a daily basis outside of work:
When choosing your vision correction surgeon, what matters most to you?*
- Affordability
- Convenience
- Safety
- Experience From Doctor
- Other
How soon would you consider laser vision correction?*
- ASAP
- Weeks
- Months
Do you have any of the following? (check all that apply)*
- Rheumatoid Arthritis
- Lupus
- Keratoconus
- Prior Eye Surgery
- Multiple Sclerosis
- I am currently Pregnant or Breastfeeding
- Cataracts
- Prior Eye Injury
- None of the Above
Name*
First Last
Email*
Phone*
Date of birth*
Date Format: MM slash DD slash YYYY
CAPTCHA

Schedule your FREE LASIK consultation
- Name*
  First Last
- Email*
- Phone*
- Date of Birth*
  Date Format: MM slash DD slash YYYY
- Preferred Day*
- Preferred Time*
- Comments
  This field is for validation purposes and should be left unchanged.

Careers

Cataracts

LASIK

Eye Surgical Associates

Contact Us

Call 402.484.0900

1710 S. 70th Street
Lincoln, NE 68506

Schedule a free LASIK Consultation
- Name*
  First Last
- Email*
- Phone*
- Date of Birth*
  Date Format: MM slash DD slash YYYY
- Preferred Day*
- Preferred Time*
- Comments
  This field is for validation purposes and should be left unchanged.

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