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Patient Mentor Program
Get in Touch with Other LASIK MD Patients
Want to speak to a former patient about their laser vision correction and their experience at LASIK MD? We will put you in contact with satisfied patients who are eager to spread the news to potential patients. We have patients from all corners of the world who have benefited from the renowned experience and latest technology available at a LASIK MD clinic. If you would like to speak to a LASIK MD patient directly about their personal experience, please fill out this form, and we will gladly match you up with a former LASIK MD patient. All fields must be completed in order to submit this form.

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Personal Information

First name

Last name

Address

City/Town

Country

Province/State

Postal Code/ZIP

Email address

Phone number

(

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Date of birth

Clinic where surgery will likely be performed

Information on your Eyes

	Right eye (OD)	Left eye (OS)
Your prescription:

Do you presently wear bifocals?	Yes No
Have you already undergone laser vision correction?	Yes No

Have you completed your FREE consultation at LASIK MD?

Yes No