.:Physician Eye Center | .:Professional Optics

At Southeast Texas Laser Eye Institute, our goal is to educate each patient to ensure they make informed decisions regarding laser vision correction. Please take time to fill out the following information to help us determine how laser vision correction can help you.

1. Personal Information

First Name

Last Name

*E-mail Address
Daytime Phone#
Evening or Alternate Phone#
Best Time to Reach You
Occupation

How did you hear about us?(If radio or TV, please specify station or channel.)

Did we mail information to you?


1. Motivation
Please specify your reasons for seeking laser vision correction.
Career Motivation
Sports Motivation:
Contact Lens Difficulties
Spectacle Difficulties
Simply fed up with poor vision without correction Yes
 
2. Prescription Glasses
Do you currently wear Glasses?


If yes, please answer the following:
Please select type of Glasses

Distance Only

  Bi-focals
  Tri-focals
  Progressive (no-line)
  Reading Glasses Only
How many years have you been wearing glasses?




Does your prescription change significantly ever year?


 
3. Contact Lens Wear
Do you currently wear contact lenses?


Did you wear contact lenses in the past?


If yes to either question, please answer the following:
Please select type of contacts Soft Daily Wear
  Soft Extended Wear
  Disposable Contacts
  Soft Toric Lenses
  Rigid Gas Permeable
  Hard Contacts
How many years have you used contacts?
When did you last use your contacts?
   
Strict Confidence  

This information is strictly confidential. Your answers will help determine if you are a suitable candidate. Health related issues must be provided to our staff at our office only and cannot be supplied online.

Beaumont: 409-832-2085   -   Port Arthur: 409-985-2745   -   Toll Free: 1-877-405-2745 (1-877-40-LASIK)