Farmington Laser Eye Center - Information Request Form

PERSONAL INFORMATION

First Name:
Last Name:
Age:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:

How did you hear about us?:

*E-MAIL ADDRESS (Please include for quicker response)**

E-Mail:

YOUR EYES

Are You (or do you have)?

Near-Sighted -- see close objects clearly
Far-Sighted -- see distant objects more clearly than you see close objects
Astigmatism -- objects are blurry regardless of distance
Presbyopia -- you only wear glasses to read

When do you wear your glasses or contacts?

All the time
Only when it is dark
When I drive
When I read

ADDITIONAL INFORMATION & QUESTIONS

Please use this space to include any additional information you may feel is relevant, or ask any additional questions:

Would you like to schedule a FREE consultation?

Yes No

Would you like to attend a FREE Lasik Seminar?

Yes No

SUBMIT FORM

FREE Financing available!

If you prefer to Call Direct and Schedule an Appointment, Please dial
(877) 40-LASER or (248) 851-7450

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