Virginia Eye Institute - Bringing your world into focus

What is your current eye glasses prescription? Please refer to your written prescription.

SPH (power)

CYL (cylinder)

OD (right)

Check here if you do not have your prescription or you are not sure.

Thank you for your interest in LASIK and refractive surgery at Virginia Eye Institute. To complete your online evaluation, please andswer the following questions to the best of your ability. Your questionaire will be reviewed and you will be contacted within 2 business days with your results.

What is your current contact lens prescription? Please refer to your written prescription or contact lens box.
	SPH (power)	CYL (cylinder)		AXIS
OD (right)			x
	Base Curve	Diameter

OS (left)	SPH (power)	CYL (cylinder)	x	AXIS

	Base Curve	Diameter

Check here if you do not have your prescription or you are not sure.

Which of the following best describes your vision? Check all that apply.
		Myopia (nearsightedness) - Close objects look clear, but distance objects appear blurred.
		Hyperopia (farsightedness) - Close objects appear blurred.
		Astigmatism - Both near and far objects are distorted or appear blurred.
		Presbyopia - Difficulty reading at close range (typically age 40 +)

Please list any known eye conditions or eye surgeries:

What occupation, sports, or hobbies do you expect to be more enjoyable after surgery:

Please tell us how you heard about us. Check all that apply.
	Radio -	Friend/Family
	Newspaper -	Doctor -
	Website/Internet	Billboard

Are you a Virginia Eye Institute patient?		No	Yes, Dr.
Do you have a LASIK physician preference?		No	Yes, Dr.

Please complete the following so that we may contact you:
First Name:	*
Last Name:	*
Address:	*
City:	*
State:	*
Zip Code:	*
Age:	*
Birthdate:	* (mm/dd/yyyy)
Telephone:	*
Email:	*
Virginia Eye Institute provides online information by way of Internet for communication and review purposes only. This evaluation is not intended to provide medical information, rather it is for informational purposes only. Any person reviewing this evaluation should obtain specific medical advice and answers to specific medical questions by a consultation with a qualified eye doctor.

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     Virginia Eye Institute
     400 Westhampton Station
     Richmond, Virginia 23226

     Appointments: 804-287-4216
     Information: 804-287-4200
     VA Toll Free: 800-348-2393
     Fax: 804-287-4210
     Email: info@vaeye.com

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