Free Screening Appointment Form

If you would like to schedule an appointment for a free screening to find out if you are a candidate for Laser Vision Correction, please fill out the following form or call our office at 
(912) 355-9020.

Name
Address
City	State	Zip Code
E-mail Address
Who referred you?
Do you currently wear contact lenses or glass? Hard Contact Lenses Soft Contact Lenses Glasses Neither Toric Soft Contact Lenses
Are you Nearsighted or Farsighted? Nearsighted Farsighted Neither Astigmatism
If you know your prescription, please provide it here.