1-800-20HAPPY

OptiVision Laser Centers

Do you want to visit OptiVision for a free, no-obligation consultation?
Call 1-800-20-HAPPY to book your appointment today at one of our
three convenient locations!

If you want more information, please fill out the following form below and one of our qualified technicians will contact you to ensure all of your questions are answered. Be sure to include your first and last name, your e-mail address and phone number. Your information will NOT be sold to outside individuals or businesses for telemarketing.

Do you think you're a candidate for laser vision correction surgery?

To be eligible for the surgery, you must meet the following criteria:

Over 18 years of age
Mild to severe farsightedness, nearsightedness or astigmatism
Not pregnant or nursing
Stable vision
Healthy eyes and corneas

Name:
Phone:
Best Time to Contact:
Address:
City:
State
Zip:
E-mail:

Are you:
Nearsighted?	Yes No
Farsighted?	Yes No
Astigmatic?	Yes No

Do you wear glasses or contacts?
Yes
No

What's your prescription? (optional)
Right Eye:

Left Eye:

When do you wear corrective lenses?
All the time
Reading
Driving
Only at night

Do you have any questions or comments?

How did you hear about us?

Search Engine
Magazine or Newspaper*
Friend/Family Member
Direct Mail
Typed in Web Address

VISX
Television
Radio
Yellow Pages
Other*

*Other:
*If magazine or newspaper, which one?