Am I Suitable?

This short questionnaire serves as an initial test to determine whether you are a suitable candidate for laser eye treatment. Please answer all questions as accurately as possible. After evaluating the questionnaire, we will contact you as soon as possible. Thank you very much for your efforts.

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Am I suitable

Title

Mr

Ms

First Name

Surname

E-Mail *

Phone (incl. Country Code)

We will be happy to call you back for a consultation.

Age

What is your visual impairment?

Nearsightedness (myopia)

Farsightedness (hyperopia)

Presbyopia (Age Related Farsightedness)

Mehrfachantwort möglich

How is your eye prescription?

e.g. -3.5 dpt for myopia

Do you suffer from astigmatism?

Yes

No

What are the diopter values ​​of your astigmatism?

On your prescription these are the cylinder values, CYL

Do you suffer from eye diseases such as cataracts or glaucoma?

No

Yes

Have you had eye surgery before?

No

Yes

Laser eye surgery

I choose ...

iLasik offer

ReLEx Smile offer

Call back service

I also have the following question!

The data is collected in accordance with our data protection guidelines.

Confirm that you are human!

If you are human, leave this field blank.