How did you find our web site?
__ Family/friend
__ Saw web address on TV/print ad
__ Internet Ad
__ Search Engine (which one?)___________________________


Please contact me with more information about:
__ LASIK - Laser Assisted In-Situ Keratomileusis
__ LTK - Laser Thermal Keratoplasty
__ PRK - Photo Refractive Keratectomy

What type of corrective devices do you use? (check all that apply)
__ Glasses
__ Bifocals
__ Soft Contacts
__ Hard Contacts
__ Other (please explain)_____________________________

What is your prescription? _____________________________

Do you have an astigmatism? Yes / No

To your knowledge, are there any other eye conditions that exist?

_____________________________________________________

What factors are most important to you when choosing a LASIK surgeon: (check all that apply)

__ Experience
__ Cost
__ Outcomes
__ In Office Experience

Please provide the following if you would like us to send you general information on the Denver Eye Clinic and laser vision correction.

Name:	______________________________
Address:	______________________________
City:	______________________________
State:	______________________________
Zip:	___________________
Phone number:	___________________
Fax number:	___________________
Email:	______________________________

Questions and comments: