Suitability Test Step 1 of 8 0% Do you wear:* Spectacles Contact Lenses Both Name* First Last Gender* Male Female Date of Birth* DD MM YYYY How would you like to receive your test results?* Email Phone Email* Phone* Without your glasses/contact lenses do you have trouble seeing:* Up Close Far Away Both What sort of contacts do you wear?* Soft / Disposable Hard / RGP What type of soft disposable contacts?* Daily Disposable Fortnightly Disposable Monthly Disposable Other Do you sleep in your contact lenses overnight?* Yes No Has your prescription changed in the last 2 years?* Yes No Upload a photo of your contact lens box or prescription (Optional) Drop files here or Accepted file types: jpg, gif, png, pdf. When are you thinking of having the laser eye surgery procedure?* As soon as possible 1 - 3 months 3 - 6 months 6 - 12 months Undecided What 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 apply Do 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 apply Do you have any allergies to medications?* Yes No Does 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 apply Are you pregnant?* Yes No Are you breastfeeding?* Yes No 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 lenses Cosmetic - I want people to be able to see my eyes without spectacles in the way Freedom - I want to reduce my dependence on spectacles and contact lenses Discomfort - My contact lenses are becoming less comfortable Cost - Contact lenses and spectacles cost too much Career - I need to be able to see without spectacles or contact lenses for work Do you know anyone who has laser vision correction?* Yes No Was it at the Lions Eye Institute?* Yes No Were you given a recommendation to a particular doctor?* Professor Graham Barrett Dr Steven Wiffen Dr Andrea Ang Not sure How did you hear about us?* Internet Search Nova Facebook Gym/Fitness Centre Friend Family Work Colleague Postcode*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country
