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Eligibility form

The eligibility for laser eye surgery form.

To confirm a specific date, please carefully fill in the following form on the surgery’s suitability. After completing the form, we will contact you for more information.

Do you wear glasses?
Do you wear contact lenses?
Do you have a problem with night vision?
The date of the last eye examination

OTHER RESULTS OF THE EYE EXAMINATION

Has the value of your diopters changed in the last half year by more than 1.0 diopter?
If you are more than 40 years old, do you need reading or other glasses or contact lenses, or do you not use glasses for reading at all?
Why are you considering laser correction?
What do you expect from the surgery?

THE DIOPTER VALUE

Left eye

SPH:

Left eye

CYL:

AXIS:

Right eye

SPH:

Right eye

CYL:

AXIS:

WHAT IS YOUR CURRENT HEALTH STATUS?

Diabetes
Autoimmune or rheumatic disorder
Pacemaker
Pregnancy/breast feeding or plan to become pregnant in the next 3 months
Psychiatric/Psychological therapy/Depression
Allergy to medicinal products
Other health problems
What medications are you currently taking?

WHAT IS YOUR CURRENT HEALTH STATUS?

Do you have or have had problems with your eyesight?
 
Did you undergo correction of vision in the past
 
In the past, did you encounter a recommendation that the laser correction of vision is not suitable for you?

DRY EYES

Have you noticed any symptoms of dry eyes?

Partners

Shin nippon

Zeiss

Alcon

Ziemer

Oculus

Nidek