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OLD BRIDGE, NJ
(732) 679-6100
RIDGEWOOD, NY
(718) 456-9500
MANHATTAN, NY
(212) 764-2020
ELMHURST, NY
(
718) 674-1957
LASIK & Alternatives
Cataracts
Other Services
Keratoconus
Corneal Cross Linking
Topo-Guided PRK
DSAEK
Dry Eye
Macular Degeneration
Glaucoma
Diabetic Eye Disease
About
Why CEI?
Dr. Ilan Cohen
Dr. Morar
Dr. Argano
Dr. Chen
Dr. Dhandia
Contact Us
Testimonials
Media
In the News
Blog
International Patients
Locations
Old Bridge, NJ
Elmhurst, NY
Manhattan, NY
Ridgewood, NY
Queens, NY
Menu
LASIK & Alternatives
Cataracts
Other Services
Keratoconus
Corneal Cross Linking
Topo-Guided PRK
DSAEK
Dry Eye
Macular Degeneration
Glaucoma
Diabetic Eye Disease
About
Why CEI?
Dr. Ilan Cohen
Dr. Morar
Dr. Argano
Dr. Chen
Dr. Dhandia
Contact Us
Testimonials
Media
In the News
Blog
International Patients
Locations
Old Bridge, NJ
Elmhurst, NY
Manhattan, NY
Ridgewood, NY
Queens, NY
Book Your Appointment
LASIK Eligibility Quiz
At Cohen eye Institute we offer a wide menu of Refractive Surgery. From Lasik to EVO- ICL. This quiz will help us help you tailor your vision to your lifestyle needs.
Age
Under 21
21 - 30
31 - 40
41 - 50
50+
Correction currently used ( glasses, contacts, bifocal/ progressive) check all that apply
Glasses for distance
Contacts
Glasses for near
Bifocals/ progressive
If you have your last glasses Rx please input it below
Do you have any eye diseases (check all that apply)
Cataracts
Keratoconus
Macular degeneration
Glaucoma
None
Other
Have you ever been told you have thin corneas?
Yes
No
Unsure
Do you feel like your eyes are dry, or are you currently being treated for dry eye?
Yes
No
Unsure
Have you had any previous eye surgeries ?
Lasik
PRK
CXL ( corneal cross linking)
Cataract surgery
Corneal transplant
Other
None
Do you have any medical conditions (check all that apply)
Diabetes
Hypertension
Rheumatoid Arthritis
Lupus
Other
None
Are you currently pregnant ?
Yes
No
Not applicable
Are you taking steroids of any other immunosuppressant medications
Yes
No
Unsure
Preferred procedure?
LASIK
ICL (Implantable Collamer Lens)
First Name
Last Name
Email
Phone Number
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