MVI LASIK EVALUATION
This form should be completed by the patient who is considering Laser Vision Correction at Medical Vision Institute.

Please be as detailed as possible as your responses will be directly sent to Dr. Dudee and the eye care team, and will be used to assess your suitability for LASIK.

This electronic form meets Private Health Information privacy requirements under HIPAA (Health Insurance Portability and Accountability Act of 1996).

(Fields marked with an asterisk must be completed to move to the next question)

Email address
First Name
Your answer
Last Name
Your answer
DOB
MM
/
DD
/
YYYY
Referral Source
Your answer
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