Suitability Test Step 1 of 8 0% Name* First Last Gender* Male FemaleDate of Birth* DD MM YYYY AgeEmail* Phone*What is your preferred contact method* Email Phone Do you wear:* Spectacles Contact Lenses BothWithout your glasses/contact lenses do you have trouble seeing:* Up Close Far Away BothWhat sort of contacts do you wear?* Soft / Disposable Hard / RGPWhat type of soft disposable contacts?* Daily Disposable Fortnightly Disposable Monthly Disposable OtherDo you sleep in your contact lenses overnight?* Yes NoHas your prescription changed in the last 2 years?* Yes NoUpload a photo of your contact lens box or prescription Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB, Max. files: 2. When are you thinking of having the laser eye surgery procedure?* As soon as possible 1 - 3 months 3 - 6 months 6 - 12 months UndecidedWhat 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?* Yes NoDoes 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?* Yes NoAre 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 workPlease provide any additional information you think will assist us in determining your suitability Do you know anyone who has laser vision correction?* Yes NoWas it at the Lions Eye Institute?* Yes NoWere 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 ColleaguePostcode*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
