LASIK and VISIAN Self Evaluation - Boston | Wellesley | Leominster | New England Eye Center

Do you have trouble seeing far away or up close?

Up close

Far away

Or both

How interested are you in being able to play sports without glasses and contacts?

It's very important to me NOT to wear glasses for activities such as sports.

It's not important to me. I do not mind wearing glasses.

What is your age?

Under 21

21 - 40

41 - 69

70+

Are you interested in seeing well up close (reading) without glasses?

It's very important to me NOT to wear reading glasses.

It's not important to me. I do not mind wearing reading glasses to see things up close.

Do you wear contact lenses or glasses?

Glasses

Contact lenses

Would your career or business activities improve if you were to become less dependent on glasses and contacts?

Yes

No

Maybe

Have you ever heard of the Visian implantable contact lens?

Yes

No

If yes, how long have you been considering the procedure?

I am not considering it

Less than 6 months

6 months to 1 year

1 year +

How long have you been considering LASIK?

I am not considering it

Less than 6 months

6 months to 1 year

1 year +

Have any of your friends or family members had vision correction surgery at our facility?

Yes

No

Are you interested in a particular surgeon?

Helen Wu, MD

Ken Kenyon, MD

Michael Goldstein, MD

Daniel Hu, MD

Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure there are associated risks. Are you willing to discuss these risks with our LASIK coordinator?

Yes

No

Name:
Phone:
E-Mail:


New England Eye Center Laser Vision Center - Boston 260 Tremont Street Biewend Building, 11th floor Boston, MA 02111 Telephone: 617-636-7800	New England Eye Center - Wellesley One Washington Street, Suite 212 Wellesley, MA 02481 Telephone: 781-237-6770	New England Eye Center at Health Alliance Leominster 20 Commercial Road Leominster, MA 01453 Telephone: 978-534-6100