1311 N. Elm Street Greensboro, NC 27401 - 1307 Coach Road Reidsville, NC 27320 - 1.800.422.8711

Schedule A Free LASIK Evaluation

Find Out If You're A Candidate For LASIK

There are many refractive surgery options available today. We know that not everyone is a candidate for refractive surgery, and we believe when it comes to your eyes, being careful is the right thing to do. Only a careful evaluation of your eyes will determine which procedure is right for you.

If you are considering refractive surgery, your first step is to make an appointment for a free evaluation to see if you are a good candidate.

You can contact us to book an appointment. We will call you back to confirm the day and the time of your appointment.

Prefix:

First Name:

Last Name:

E-mail address:

Date of Birth:

Address:

Address 2:

City:

State:

Zip:

Day Phone:

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Evening Phone:

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Eye Care Provider:
Do you wear glasses or contacts?
Do you have trouble seeing far away or up close?	Yes No
Are you pregnant or nursing?	Yes No
Have you been diagnosed with one or more of the following?
rheumatoid arthritis fibromyalgia keloids uncontrolled diabetes corneal eye disease amblyopia
I would like a screening on one of the following days:
Tuesday Wednesday Thursday Morning Lunchtime Afternoon
Comments:

You will receive a call back from Shapiro Eye Care to confirm day and time.

Click here to Shedule a free lasik evulation

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