LASIK, is it right for me? How old are you?*Do you have trouble seeing?*- Please Select -Far awayClose upBothHas your prescription changed significantly in the last 2 years?- Please Select - YesNoDo you usually wear glasses or contact lenses?*- Please Select - GlassesSoft contact lensesHard contact lensesBoth glasses and contact lensesI don’t wear anyHave you been diagnosed with any of these eye conditions?- Please Select - KerataconusCataractsGlaucomaRetinal diseaseSevere dry eyeCorneal scarringLazy eyeOtherWhich Other Eye Condition?*Have you previously had eye surgery?- Please Select - YesNoPlease advise, which surgery you have had*Have you been told that you are NOT a good candidate for LASIK surgery?(We can tell you about other options.)- Please Select -YesNoDo you suffer from any of the following medical conditions?- Please Select - None- I am healthyDiabetesRheumatoid arthritisAutoimmune diseases such as lupusMultiple SclerosisCollagen vascular diseaseI am currently pregnantWhat is your biggest concern about having LASIK surgery?- Please Select -No concernsMoving my eyes or head during laser treatmentExpenseAchieving the best vision possibleNeeding glasses or contacts againHaving to still wear reading glasses when I’m olderOtherHow soon would you like to improve your vision?Within the next 3 months3 to 6 monthsMore than 6 monthsI’m not sureWould you like more information or to book a consultation?*- Please Select -Information onlyBook a consultation with Dr Phil at MurdochBook a consultation with Dr Phil at SubiacoHow did you hear about Perth Laser Vision?*- Please Select -Family/friendGoogleFacebookRadioOnline Banner AdGPOptometristYour Contact DetailsFirst Name*Last Name*Email Address* Phone Number*Date of Birth Date Format: DD slash MM slash YYYY Address* Street Address City State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Write Your MessagePhoneThis field is for validation purposes and should be left unchanged.