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What is Lasik
 
 
-Please Fill Out This Form Entirely Describing Your Poor LASIK Outcome-
 

What is your primary complaint from LASIK Surgery?


How long have you been having these problems?


Do you feel you were completely informed of all known LASIK risks?


What City/State Located?


   

Date of LASIK Surgery:

 

 

Name of LASIK Doctor:

 

Name of LASIK Clinic:

 

   

*

Your Name

 

Your Spouse (if had LASIK )

Your Current Address

 

*

Phone Numbers
Provide at least one phone number please.
Example: 555-555-0000

*

E-mail Address
Example:  ruinedeyes@badlasik.com

*

Verify E-mail Address


    

 

When should we contact you?  

*

How did you hear about us?

 

Additional Comments (if any) about your concerns
regarding your LASIK Surgery or your
LASIK Doctor:

     
 
     
 

Click "SUBMIT BUTTON"
When Finished



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