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Laser Eye Care Center
Sansum Clinic / Laser Eye Care Center / Contact Laser Eye Care Center / Laser Eye Care Center Questionnaire

Are You a Candidate for Laser Eye Surgery?

Submit our questionnaire and our LASIK Eye Coordinator will get back to you with more information about whether Laser Eye Surgery is right for you. 

Sansum Clinic Laser Eye Care Center 4151 Foothill Road
Santa Barbara, CA 93110
(805) 681-8951
Email: lasik@sansumclinic.org 
Hours: Mon-Thurs, 8 AM to 5 PM; Fri, 8 AM to 12 Noon

(xxx) xxx-xxxx (optional)

Gender

Do you currently wear glasses or contact lenses?

What type of refractive error do you have?

Do you have astigmatism?

Has your vision correction -- that is, your glasses or contact lens prescription -- changed over the past year or two?

Do you have any of the following conditions? (Please select all that apply.)

Are you currently taking medications, such as steroids or immunosuppressants, which can slow or prevent healing?

Do you have any of the following conditions? (Please select all that apply.)