Registration for examination

Dear Customer,

Now is the perfect time for you to forget the annoyances of wearing glasses and contact lenses forever and free yourself from the hassles and expenses of its daily use.

If you decide that you would like to get rid of your glasses or contacts, all you have to do is fill out the following form and send it to us. It automatically registers you for an eye exam and our staff will call you to schedule an appointment. If your general health and the health of your eyes show that you are a candidate, the next step, based on your request, would be to perform the laser eye treatment developed by Bausch & Lomb. International tests have shown that these procedures have the best results in laser eye correction.

Your cooperation assists us in completing a successful examination and treatment. Thank you!

Name:
Phone number:
E-mail address:
Application for an eye exam
Filling in the following gaps is not a must, but you can help us to solve your problem easier. So please try to fill in. Thank you.
Age:
Country:
City:
Address:
ZIP Code:
What type of vision problem do you have?		Nearsighted Farsighted Presbyopia Other
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SUPRACOR -
freedom from reading glasses!