ON LINE EVALUATION Please fill out this form and press the
SUBMIT button at the end. We will be contacting you shortly to let you know if you are,
or are not a candidate for laser eye surgery.
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or are using Internet Explorer version 3.0 for Windows 95, or version 3.0
for Windows 3.1, please send the information by regular E-mail fperdomo@sol.racsa.co.cr or print out and fax the form to (506) 231-7342.
Name:
E-mail:
Phone No. (with country code):
Fax No. (with country code):
Address:
City:
Prov./State:
Postal or Zip code:
Date of Birth:
Type of disorder you have: Myopia (nearsightedness or
shortsightedness),
Hyperopia
(farsightedness), Presbyopia, Astigmatism
Graduation of glasses or contact lenses that you are using at this time (for both eyes),
Right eye: Left eye:.
At this time we DO OPERATE ALL THE REFRACTIVE DISORDERS except
presbyopia or keratoconus, but we will soon be operating on presbyopia
Age: Sex:
Type of work:
What is the sharpest measurement of vision that you are capable of using contact lenses or
glasses.
(Using the Schnellen measurement, example: 20/20 for both eyes),
Right eye: Left eye:.
If you have any other eye disorder, please specify: