Discover if You're a Candidate for EVO ICL

The Implantable Collamer® Lens, or ICL™, was designed to be placed within an eye, overlying the eye’s natural lens, to correct nearsightedness, farsightedness, and astigmatism. No corneal tissue is removed, making this procedure an option for patients with thin or irregular corneas who would otherwise not qualify for laser vision correction.

Treatment Name

Lead Type

Please fill out this brief form to request your Laser Vision Correction consultation at Visionmax Eye Centre

First, do you currently wear glasses or contacts? *

Yes, glasses

Yes, contacts

What are you hoping to accomplish with Laser Vision Correction treatment? *

No longer have to wear corrective lenses

Correct Astigmatism

Correct Nearsightedness

Correct Farsightedness

No longer have to wear contacts

No longer need reading glasses

Other

What is your first name? *

How long have you been considering Laser Vision Correction? *

Many years

About 1 year

For the last 6 months

Recently started to consider it

Other

How soon would you like to have clear vision? *

As soon as possible

Within two weeks

Within the next month

Within three months

Other

Do you live or work within 25 miles/km of our location? *

Yes

What is your last name? *

Which day is best for your consultation? *

Monday

Tuesday

Wednesday

Thursday

Friday

Next, a member of our team will be calling to finish the scheduling process.

What is your cell phone number? *

Also, we will send you an email confirmation for your consultation request.

What is your best email address to receive this notification? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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