Online consultation

Is laser eye surgery right for you?

Please fill the form and get answer till:
2018-09-21, Friday, 4 p.m.

[[[["field3","equal_to","Female"]],[["show_fields","field4"],["hide_fields","field58"]],"and"],[[["field11","equal_to","Yes"]],[["show_fields","field17,field18,field60"]],"and"],[[["field14","equal_to","Yes"]],[["show_fields","field19,field20"]],"and"],[[["field22","equal_to","Yes"]],[["show_fields","field23"]],"and"],[[["field24","equal_to","Yes"]],[["show_fields","field25"]],"and"],[[["field26","equal_to","Yes"]],[["show_fields","field27"]],"and"],[[["field59","equal_to","1"]],[["show_fields","field63"]],"and"],[[["field59","equal_to","2"]],[["show_fields","field47,field50,field48"]],"and"],[[["field59","equal_to","2"],["field56","not_equal_to","appointment-7"]],[["set_value",null,"appointment-7",null,"field56"]],"and"],[[["field59","equal_to","1"],["field56","not_equal_to","appointment-6"]],[["set_value",null,"appointment-6",null,"field56"]],"and"],[[["field59","equal_to","1"],["field59","equal_to","2"]],[["show_fields","field62"]],"or"],[[["field65","equal_to","1"]],[["show_fields","field64,field2,field54,field5,field34,field37,field45,field33,field51,field52"]],"and"],[[["field59","equal_to","1"],["field62","contains"],["field63","contains"],["field65","not_equal_to","1"]],[["set_value",null,"1",null,"field65"]],"and"],[[["field59","equal_to","2"],["field62","contains"],["field65","not_equal_to","1"]],[["set_value",null,"1",null,"field65"]],"and"]]
1 EYESIGHT
2 HEALTH
3 REQUEST
Do you wear glasses?
When do you use glasses?
Left eye - please specify the power (diopters) of your glasses, If don't know, leave empty...
0 /
Right eye - please specify the power (diopters) of your glasses, If don't know, leave empty...
0 /
Do you wear lenses?
Left eye - please specify the power (diopters) of your lenses, If not sure, leave empty...
0 /
Right eye - please specify the power (diopters) of your lenses, If not sure, leave empty...
0 /
Gender (sex)
Are you pregnant or are you breastfeeding now?
Do you use any kind of medications every day (drops, tablets, etc.)?
If yes, specify what:
0 /
Had you any kind of surgery (operation) before?
If yes, specify what:
0 /
Allergies / Special Health Considerations?
If yes, specify what:
0 /
Thank you for completing the questionnaire. According to your data, our specialists will give you initial answer if laser vision correction is suitable for you. If the first assessment is positive, you will receive scheduled visits in line with your wishes for:
  • full eyes examination and laser vision correction;
  • full eyes examination without scheduled laser vision correction.
Do you plan surgery in near future?
Appointment details for consultation
×
Clinic
Date
Select a clinic
Appointment details for surgery
×
Clinic
Date
Select a clinic
Please provide your contact details so we can contact you with an answer.
First name
Last name
Phone number
Age
Commentsmore details
0 /
Contact me by:
Show contactsyour full name

PREVIOUS
NEXT Submit Form