Laser Vision Correction- Free Consult Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Kakaria Ophthalmology
Cataract and Laser Center
2005 Technology Parkway Suite 230
Mechanicsburg, PA 17050
Phone: 717-695-9355 | Fax: 717-695-9356 | Website: drkakaria.com

Email *

How old are you? *

18-20 (Acceptable but considered young for surgery. You may want to wait.)

21-39 (Can achieve excellent vision for distance and near. Will need reading glasses around age 40.)

40-59 (Will have slower healing with more fluctuations in vision. Will need reading glasses.)

60+ (You might as well wait for cataract surgery.)

Do you wear glasses, contact lenses, or both?

Glasses only (You may be a great candidate but you will be more anxious when we touch your eyes.)

Contacts only (You will need glasses first because you will have to be out of your contact lenses for one week before the consult.)

Both- Glasses and Contacts (You may be a great candidate. Please stay out of your contact lenses for one week before the consult.)

Clear selection

Are you nearsighted or farsighted, with or without astigmatism? *

Nearsighted (Can see at near without glasses but needs glasses for far away.)

Farsighted (Can see far away without glasses but needs glasses for near.)

How high is your nearsighted or farsighted prescription?

-1.00 to -3.00 (Faster healing with great results.)

-3.00 to -6.00 (Medium-paced healing with great results.)

-6.00 to -9.00 (Slower healing with great results, but a higher need for additional surgery.)

+1.00 to +3.00 (Slow, farsighted healing with great results.)

Outside of these ranges (Not a good candidate for laser vision correction.)

Clear selection

Are you pregnant, trying to get pregnant, or currently breastfeeding?

Yes (You are not a candidate for surgery at this time.)

Clear selection

Do you have a family history of keratoconus or corneal transplant?

Yes (You are not a good candidate for surgery.)

Clear selection

Do you have any eye disease that would make you a poor candidate for laser vision correction, such as keratoconus, cataracts, glaucoma, macular degeneration, diabetic retinopathy (with retinal bleeding), or severe dry eyes even without contact lens wear? If so, please explain.

Have you had laser vision correction or any eye surgery in the past? If so, please explain.

Do you understand that the consult is free but the surgery will cost $2,495 per eye and will not be covered by your health insurance?

Yes

Clear selection

Patient Name (First, Middle, Last) *

Date of Birth *

YYYY

Health Insurance *

Mobile Phone Number *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google.