By answering the form below you will get a better idea if the Visian™ ICL could enhance your lifestyle. Fill out this questionnaire and we will be happy to review your initial status.

1. I would consider myself a highly nearsighted patient and I have trouble seeing far away without glasses or contacts

    True    False

2. My dependence on glasses or contacts is a limitation for my lifestyle.

    True    False

3. I am not comfortable with contact lenses.

    True    False

4.  I was not a candidate for LASIK eye surgery.

    True    False

5. I enjoy sports and an active lifestyle.

    True    False

6. Not being dependent on glasses or contacts would be beneficial in my profession.

    True    False

7. Do you have any of the following conditions? (Please select all that apply.)
• Diabetes
• Thin corneas
• Keratoconus
• Autoimmune disease (for example, AIDS, lupus, rheumatoid arthritis, multiple sclerosis, or myasthenia gravis)
• Collagen vascular disease
• I have none of these conditions
8. Do you have a current optometrist?

    Yes    No

9. If you answered "Yes" to Question 8, who is your current optometrist if you see one?

  

QUESTIONS
If you have specific questions related to the ICL please make sure to write them in the box below and we will be happy to answer them for you.