Denver Eye Doctor Information Request Form - Centennial Eye Associates - Dr Kim Burrell DO - Board Certified Opthalmologist - Centennial Optical Center - Centennial Colorado - Laser Surgery

PERSONAL INFORMATION

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

*E-MAIL ADDRESS (Required)**

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

If you prefer to Call Direct and Schedule an Appointment, Please dial
(303) 699-3107