Realeyes Eye Laser Center

• TitleMr.Mrs.
•  
• First name *
• Last name *
• Street
• Nr.
• ZIP
• City
• Phone
• E-Mail *
• Age *

Which facts apply to you?

• My glasses affect me at work or at leisure.
• I can’t wear contact lenses or experience discomfort wearing them.
• My diopters/prescription haven’t changed for more than one year or have only changed slightly.
• I am not growing any more and I am at least 18 years old.

I suffer from one of the following diseases:

• Corneal diseases
• Cataract/glaucoma
• Retinal degenerations
• Diabetes
• None of these apply to me.

Nearsightedness, farsightedness, astigmatism?

• I am nearsighted and need my glasses/contacts for distance vision.
• I am farsighted and need my glasses/contacts at all times for near vision.
• I have astigmatism (irregular curvature of the cornea).
• I have presbyopia and need my glasses for reading.

Prescription/diopters:

• right Eye:
• left Eye:

Visual acuity

• right Eye:
• left Eye:

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