Free LASIK Pre-Screening Test

If you would like any further information on the treatment options we can offer then please fill in the form below, click submit and one of our healthcare executives will contact
you within 24 hours. Alternatively you can email us directly at info@surgeryabroad.org.uk

Name*

Age*

years

Sex*

Male Female

Address*

City

Postcode*

Telephone*

*Prefered time to call

Email address*

Prescription

Right Eye

Left Eye

SPH CYL

Please answer the following questions: 1. Have you had a change in your glasses or contact lenses prescription in the last year?
Yes	No	I do not know.
2. Are you currently pregnant or nursing?
Yes	No
3. Have you ever had any kind of eye disease/illness and/or eye operation?
Yes , pl. specify		No
4. Are you currently taking any medicine?
Yes, pl. specify		No
5. Do you feel very dependent upon your glasses or contact lenses?
Yes	No
6. Do your hobbies or occupation require perfect vision?
Yes	No
7. Do you feel any discomfort at the end of the day with your contact lenses?
Yes	No