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Steen-Hall Eye Institute, Shreveport, LA
Are you a candidate for LASIK?  
To find out if you are a candidate for LASIK just take a moment to fill out the following questionnaire. Be sure to include your email address (since it is not automatically supplied), and click on the "Submit" button below.

LASIK patients must be 18 years of age or older and have healthy eyes. This questionnaire simply allows us to determine if you meet the basic criteria for LASIK. Before performing any procedure you would have a complete eye exam at our Refractive Surgery Center.

Name
Company
Address1
Address2
City
State
Zip
Country
Telephone
Fax
Email
Do you wear? Glasses
Hard Contacts
Soft Contacts
Are you? Nearsighted
Farsighted
Do you have astigmatism? Yes
No
What is your prescription?
(available from your doctor)		 Right:      Left: 
How would you like to be
notified of your candidacy?		 Telephone
Email
Mail
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