Step 1 of 7 0% firstname_encryptedlastname_encryptedfullname_encrypteddob_encryptedphone_encryptedemail_encryptedWithout your glasses/contact lenses do you have trouble seeing:*Up CloseFar AwayBothWhat sort of contacts do you wear?*Soft / DisposableHard / RGPWhat type of soft disposable contacts?*Daily DisposableFortnightly DisposableMonthly DisposableOtherDo you sleep in your contact lenses overnight?*YesNoHas your prescription changed in the last 2 years?*YesNoUpload a photo of your contact lens box or prescription (Optional) Drop files here or Accepted file types: jpg, png, pdf, . When are you thinking of having the laser eye surgery procedure?*As soon as possible1 - 3 months3 - 6 months6 - 12 monthsUndecidedWhat age did you start wearing glasses or contact lenses? (estimate)* Do you participate in any of the following?* None of these Contact Sports Martial Arts Surfing Swimming Diving Skydiving Adventure Sports (e.g. Bungee Jumping) Tick any that applyDo you wear spectacles or contact lenses when doing the following:* None of these Driving Reading Using a Computer/iPad Do you have any of the following eye conditions:* None of these Hayfever Dry eyes Keratoconus (or other corneal thinning disorder) Corneal Scarring Glaucoma Cataracts Ocular Herpes (diagnosed in the past year) Tick any that applyDo you have any allergies to medications?*YesNoDoes anyone in your family have any of the following conditions:* None of these Blindness Glaucoma Cataracts Retinal detachment Macular degeneration Keratoconus (or other corneal thinning disorder) Tick any that applyAre you pregnant?*YesNo What is your main reason for seeking LASIK?*Lifestyle - I want to be able to do everything I want without worrying about spectacles or contact lensesCosmetic - I want people to be able to see my eyes without spectacles in the wayFreedom - I want to reduce my dependence on spectacles and contact lensesDiscomfort - My contact lenses are becoming less comfortableCost - Contact lenses and spectacles cost too muchCareer - I need to be able to see without spectacles or contact lenses for work Do you know anyone who has laser vision correction?*YesNoWas it at the Lions Eye Institute?*YesNoWere you given a recommendation to a particular doctor?*Professor Geoffrey CrawfordProfessor Graham BarrettDr Steven WiffenDr Andrea AngNot sure How did you hear about us?*Internet SearchNovaFacebookGym/Fitness CentreFriendFamilyWork ColleaguePostcode* This iframe contains the logic required to handle Ajax powered Gravity Forms.
