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The adventures of Mr Perfectsight
3 D animation
End of operation interview

Knowing everything about eye operations

Information request

So that we can draw up your excimer laser refractive treatment file, please fill in the questionnaire. You will receive a reply within 24 hours.

Totally anonymous, you can either send it to us, giving us an address e-mail at the same time, or print it and bring it with you at your consultation.

     identity
Sex: Male Female
Age:
Profession:
Post code :
     your eyes
Year of your last visit to an eye specialist:
Do you wear glasses: yes no
  all the time
Do you wear contact lenses: yes no
If yes, soft hard
Do you know how thick your cornea is? yes no
If yes, µm (microns)
     your sight
You are: short-sighted long-sighted
  astigmatic
  presbyotic
  I don’t know
Any known personal ocular antecedents: amblyopia
  conjunctivitis
  keratitis
  keratoconus
  shingles, herpes
  laser for a retina problem
  cicatrisation problems
     MISCELLANEOUS
Miscellaneous:
Email address :
 
Veuillez saisir le code inscrit dans l'image

Centre Laser Vision Roosevelt
39, cours Franklin Roosevelt - 69006 LYON - Tél. : 04 72 82 32 82 - Fax : 04 72 82 32 81 - Mail : contact@clvr.fr