LASIK Self Test - Grosinger, Spigelman & Grey

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Michigan's Leading Eye Care Physicians

Vision Correction

Take the self-evaluation to determine if you’re eligible

Age*
- Under 55
- 55+
Do you wear: (Select all that apply)
- Contacts
- Glasses
- Readers
- Bifocals/Trifocals
Without using corrective lenses, I have trouble seeing at: (Select all that apply)*
- Near
- Distance
- Intermediate
Have you ever been told that you have astigmatism?*
- Yes
- No
Do you have any of the following? (Select all that apply)
- Cataracts
- Previous Eye Injury
- Glaucoma
If you are over 40, would you be willing to wear reading glasses for close up activities following vision correction?*
- Yes
- No
- Not Applicable
Have you noticed any deterioration of your vision in the last 5 years?*
- Yes
- No
Do you have trouble with glare when driving at night?*
- Yes
- No
Do you feel that your quality of life, career, or activities you do for enjoyment would be improved if you were less dependent on glasses or contacts?*
- Yes
- No
How did you hear about Grosinger, Spigelman & Grey Eye Surgeons?*
- Google
- Word of Mouth or Friend
- Referral from Optometrist
- Referral from Medical Doctor
I would like to be contacted by Grosinger, Spigelman & Grey Eye Surgeons*
- Yes
- No
Name*
First Last
Email*
Phone*
Comments
This field is for validation purposes and should be left unchanged.

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Grosinger, Spigelman & Grey Eye Surgeons
1750 S. Telegraph Rd., Ste 205
Bloomfield Hills, MI 48302 USA

Phone: (248) 333-2900
Fax: (248) 333-3539

Mon-Thurs: 7:30AM–4:30PM
Fri: 7:30AM–3:30PM
Sat: Limited Hours Available
Sun: Closed