757-228-7373 info@supralase.com

Please, take a few minutes to fill out this self-evaluation to see if you pre-qualify for SUPRALASE®:

What is your age range? (required)

Have you ever had an eye surgery or eye injury? (required)
 Yes No

Do you have trouble seeing? (required)

Do you use corrective lenses? (required)
 Yes No

Do you know your glasses/contact prescription? (required)

Would you prefer to play sports without the hassle of glasses or contacts?
(required)
 Yes No

Would your quality of life improve if you were not dependent on glasses or contacts? (required)
 Yes No

How did you hear about us? (required)

Contact Information:

Your Name (required)

Your Address (required)

DOB (required)

Phone (required)

Your Email (required)

We look forward to you seeing us!!!!!