Refractive Questionnaire

If interested in finding out if you are a candidate for refractive surgery,
please fill out the questionnaire below. Thank you.

Last name:	First name:

Age:	Refractive Error:	Wear:

Refraction Stable:	Last Prescription Change:

Right Eye prescription:	Left Eye prescription:

Have you ever been diagnosed with: Cataracts Glaucoma
Macula Degeneration Diabetes Keratoconus
If other, please specify:

Main reason for wanting refractive surgery:

Are you interested in:

If other, please specify:

Can our office:

Would you like to schedule a:

Please enter your phone number:

Please enter your email:

Please write below any questions or concerns that you would like
Dr. Salz to answer for you:

Before you click the submit button be sure to include
your email address above if you want a reply from
Dr. Salz