The ideal candidate is over 18 years of age and has healthy corneas. Candidates must not have had a significant increase in their eyeglass or contact lens prescription in the last 12 months.  People with certain medical conditions or women who are pregnant or nursing may not be good candidates. Find out if you are a candidate for this exciting, life changing procedure, by filling out the following information below, or by calling our office at 1-888-619-2020.

Note: Required fields are shown in Red.
Please enter your name:
Mailing Address: (City, State, Zip)
Email Address:
Phone number:

Enter your eyeglass prescription below:
(Please note, cylinder may be in + or - form. If there is no cylinder, please leave it blank.)

	Spherical	Cylindrical	Axis
Right eye: (O.D.)
Left eye: (O.S.)

Disclaimer: Information gathered will be used for internal purposes only and will not be resold or shared with any organization outside of Ophthalmic Surgery of Wisconsin.