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
or email us at
centeye@msn.com