El Paso Laser Eye Surgery | Schuster Eye Center

Personal Information:
Your Name:
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Cell Phone:
E-Mail:
When is the best time for us to contact you?
Monday Tuesday Wednesday Thursday Friday
AM PM

General Information:
Gender:	M F
What is your most important reason for having laser vision correction?
Have you had any previous eye surgery/injury or medical conditions?
Why did you choose Schuster Eye Center?
Do you wear contact lenses?	Yes No
How long have you worn contact lenses?
What are the biggest problems with glasses or contact lenses?
What hobbies or activities do you enjoy doing in your spare time?
Has your prescription been generally stable for the last year?	Yes No

If you know your most recent prescription, please provide details in the boxes below:
Right Eye	Sphere: Cylinder: Axis:
Left Eye	Sphere: Cylinder: Axis: