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) ---10-1516-2021-2526-3031-3536-4041-4546-5051-5556-6061-6566-7070 and up Have you ever had an eye surgery or eye injury? (required) Yes No Do you have trouble seeing? (required) ---FarsightedNearsightedBoth 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)---TVRadioWebsiteSocial MediaFriend/FamilyOther Contact Information: Your Name (required) Your Address (required) DOB (required) Phone (required) Your Email (required) We look forward to you seeing us!!!!!