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(502) 897-1604
(800) 777-4393
LOUISVILLE, KY
About Us
Careers
Physicians
David Karp, M.D.
R. Scott Hoffman, M.D.
Alicia Herrmann, O.D.
Madison Kerley, M.D.
Conditions
Blepharitis
Cataracts
Diabetic Eye Disease
Dry Eye
Floaters
Glaucoma
Macular Degeneration
Pink Eye (Conjunctivitis)
Retina Conditions
Services
Same Day Appointments
Laser Assisted Cataract Surgery
Cataract Surgery
Contact Lens Dispensary
Comprehensive Eye Exam
Diagnosis & Treatment of Eye Diseases
Glaucoma Treatment
Right to Sight
Children’s Exams
Optical Department
Transportation
DEI Doctors Referral Form
LASIK
Patient Info
Now Accepting New Patients
DEI News
Dry Eye Questionnaire
Financing
Insurance
Kids Club
Patient Portal
Patient Forms
Patient Survey
Patient Portal
Pay Your Bill
Eye Care Blogs
Maps
Contact Us
About Us
Menu Toggle
Careers
Physicians
Menu Toggle
David Karp, M.D.
R. Scott Hoffman, M.D.
Alicia Herrmann, O.D.
Madison Kerley, M.D.
Conditions
Menu Toggle
Blepharitis
Cataracts
Diabetic Eye Disease
Dry Eye
Floaters
Glaucoma
Macular Degeneration
Pink Eye (Conjunctivitis)
Retina Conditions
Services
Menu Toggle
Same Day Appointments
Laser Assisted Cataract Surgery
LASIK
Cataract Surgery
Contact Lens Dispensary
Comprehensive Eye Exam
Diagnosis & Treatment of Eye Diseases
Glaucoma Treatment
Right to Sight
Children’s Exams
Optical Department
Transportation
DEI Doctors Referral Form
Patient Info
Menu Toggle
Now Accepting New Patients
DEI News
Dry Eye Questionnaire
Financing
Insurance
Kids Club
Patient Portal
Patient Forms
Patient Survey
Patient Portal
Pay Your Bill
Eye Care Blogs
Maps
Contact Us
Main Menu
About Us
Menu Toggle
Careers
Physicians
Menu Toggle
David Karp, M.D.
R. Scott Hoffman, M.D.
Alicia Herrmann, O.D.
Madison Kerley, M.D.
Conditions
Menu Toggle
Blepharitis
Cataracts
Diabetic Eye Disease
Dry Eye
Floaters
Glaucoma
Macular Degeneration
Pink Eye (Conjunctivitis)
Retina Conditions
Services
Menu Toggle
Same Day Appointments
Laser Assisted Cataract Surgery
LASIK
Cataract Surgery
Contact Lens Dispensary
Comprehensive Eye Exam
Diagnosis & Treatment of Eye Diseases
Glaucoma Treatment
Right to Sight
Children’s Exams
Optical Department
Transportation
DEI Doctors Referral Form
Patient Info
Menu Toggle
Now Accepting New Patients
DEI News
Dry Eye Questionnaire
Financing
Insurance
Kids Club
Patient Portal
Patient Forms
Patient Survey
Patient Portal
Pay Your Bill
Eye Care Blogs
Maps
Contact Us
Lasik Survey
A form to determine if a candidate is a good lead for LASIK surgery.
Step
1
of
5
- About You
20%
How old are you
(Required)
Please enter a number from
1
to
99
.
Have you had an eye exam within the past 12 months?
(Required)
Yes
No
Do you currently wear vision correction?
(Required)
Glasses
Contact lenses
Both glasses and contact lenses
Neither
What type of vision problem do you have?
(Required)
Nearsightedness (myopia)
Farsightedness (hyperopia)
Astigmatism
Other
I'm not sure
Please tell us about your other vision correction
You said other. What do you mean?
Has your glasses or contact lens prescription changed within the past 12 months?
(Required)
Yes
No
Not Sure
Have you ever been diagnosed with or treated for any of the following?
(Required)
If you select "None of the above," please do not select any other choices.
Keratoconus or corneal thinning
Severe dry eye
Glaucoma
Cataracts
Retinal disease
Eye infection or inflammation
Corneal disease
Herpes infection involving the eye
Previous eye injury
Previous eye surgery
None of the above
I'm not sure
Are you currently pregnant or breastfeeding?
(Required)
Select No if this does not apply to you.
Yes
No
Do you have any medical conditions that could affect your eyes or healing?
(Required)
Certain health conditions and medications may affect your eyes, healing or your vision. Our eye-care team will review this with you during your evaluation.
Yes
No
I'm not sure
Sounds Like You May Be a Candidate for LASIK!
Based on your answers, LASIK may be an option worth exploring. The next step is a comprehensive evaluation with our eye-care team to determine whether LASIK is right for your eyes.Please provide your contact information below and someone from our office will contact you.This questionnaire is only a preliminary screening tool. Final LASIK candidacy can only be determined by a qualified eye-care professional after a comprehensive evaluation.
Let's Talk About Your Vision Options
Based on your answers, LASIK may not be the best fit for you right now, but that doesn't necessarily mean there aren't other options for improving your vision.Please provide your contact information below. Someone from our office will contact you to learn more about your vision and discuss possible next steps.This questionnaire is only a preliminary screening tool and does not determine whether you are or are not a candidate for LASIK or another treatment.
Contact Information
Name
(Required)
First
Last
Phone
(Required)
Country
Phone Number
Email
(Required)
Preferred Contact Method
(Required)
Phone
Email
Either
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