Lasik Self-TestWhat is your age? Under 18 19–40 41–69 70+I wear (choose all that apply): Contacts Glasses Reading Glasses NoneHas your prescription changed over the last 2 years? Yes NoAre you currently nursing, pregnant, or planning to get pregnant in the near future? Yes NoWhat are you looking for in a LASIK Center? (choose all that apply): Financing Technology Results Experience / Reputation of Surgeon CostDid your eye doctor talk to you about New Vision Laser Center? Yes NoI authorize a New Vision Laser Center representative to contact me to discuss the results of my LASIK Self-Test. I acknowledge that the information provided in this questionnaire will be used to send additional information about offers related to our services.(Required) Yes, authorizeFirst Name(Required)Last Name(Required)Date of Birth(Required) MM slash DD slash YYYY Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code