Ezra Maguen, MD - Refractive Questionaire

If interested in finding out if you are a candidate for laser vision correction,
please fill out the questionnaire below. Thank you.

Last name:	First name:

Age:	Refractive Error:	Wear:

Refraction Stable:	Last Prescription Change:

Right Eye prescription:	Left Eye prescription:

Have you ever been diagnosed with: Cataracts Glaucoma
Macula Degeneration Diabetes Keratoconus
If other, please specify:

Main reason for wanting refractive surgery:

Are you interested in:

If other, please specify:

Can our office:

Would you like to schedule a:

Please enter your phone number:

Please enter your email:
(to a receive respose)

Please write below any questions or concerns that you would like
Dr. Maguen to answer for you: