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PPC Self-Eval

Self-Evaluation

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Welcome

Hi there, please fill out our free self-evaluation to see if you might be a good candidate for LASIK.

9Questions

1

Select your age group* This field is required

Under 18

19-39

40-59

60+

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2

What do you usually wear?* This field is required

Glasses

Contacts

Reading Glasses

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3

Without my glasses and contacts* This field is required

I have trouble reading and seeing things up close

I have trouble driving and seeing things that are far away

I've been told that I have astigmatism

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4

Do you have any of the following?* This field is required

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5

Can we get your name?* This field is required

First Name

Last Name

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6

What is your phone number?* This field is required

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7

What is your email?* This field is required

example@example.com

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8

The best way to contact you is?

Phone

Email

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9

I consent to receiving email marketing communications.* This field is required

YESNO

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10

Status

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11

Referrer

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12

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LASIK Mt. Pleasant

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Main Phone: (800) 926-7966

Exciting News!

Rosenbaum Eye and Laser Center will be transitioning to Specialty Eye Institute. Even though our name has changed, our doctors, locations, hours, phone numbers, and, most importantly, our dedication to personalized patient care, will remain the same. With this partnership, we’re excited to be able to offer an expanded set of services, locations, and physicians to our patients.

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