Preliminary qualification form for laser vision correction

This questionnaire is intended to determine if there are no unequivocal contraindications for the laser vision correction surgery – before you come to the full qualification examination.

After completing and sending the questionnaire – our specialists will analyze the results and within 3 days you will receive an answer from us or any additional questions.

The questionnaire is only indicative and does not replace the completion of a full qualification examination before a surgery.

Personal details

All fields are required

Vision error (in diopters)

Nearsightedness (-)
Farsightedness (+)
Astigmatism (please add + or -)
yes no don't know

What are you currently using to correct your vision error?

Do you or did you suffer from any of diseases listed below?

yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no

Do you have or did you suffer from?

yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know
yes no don't know

Further information

yes no don't know

Source

Please provide the source from which you learned about CM MAVIT.

Data processing agreement

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