Emory Vision - Request a Consultation

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Request a Consultation

Please fill out the form for more information. Your responses will be valuable in providing you the best care and advice. *Required Information
*First Name
*Last Name
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City
State
ZIP Code
*Email Address
Primary Phone
Male Female
*Birthday	mo/day/year
What is your reason for considering LASIK surgery? Reasons that are frequently given include improving your appearance, reducing your dependency on glasses, or for career or lifestyle reasons.

Are you willing to accept a real, but very low risk of complications from surgery? Yes No If no, please explain.

If so, will you discuss these risks and the benefits of LASIK with Emory Vision physicians and technicians? Yes No If no, please explain.

After your LASIK surgery, would you be willing to come to follow-up exams with your Emory Vision physician, and use any medications prescribed for you? Yes No If no, please explain.

Do you have diabetes, an autoimmune disease, a compromised immune system, or collagen vascular disease? Yes No If yes, please explain.

Are you currently taking immunosuppressants or steroid medications? If so what kind? Yes No If yes, please explain.

Has your eyeglass or contact lens prescription changed over the last two years? Yes No
Are you nearsighted, or farsighted?
If nearsighted, what is your prescription, if you know it?
Do you have or have you ever had any of these eye conditions: cataracts, glaucoma, corneal scarring, keratoconus, ocular herpes, retinal disease, or dry eye? Yes No If yes, please explain.

*Required Information