Corrective Eye Center

CALL US TODAY!
216 574 8900
800 535 Eyes (3937)
doctors@correctiveeye.com

Information Form

Would you like to know if you are a candidate for ReSTOR? For your convenience, we have provided this information form that directly asks for the facts we need to know to help you.

Or, you can feel free to email us at doctors@correctiveeye.com with the relevant information. (Your location is important).

Your Form Will Be
Processed Immediately Once you fill out our form, our doctors will review your information to see if you are a candidate for Correction Surgery.

***We work with many Optometrists in the Northeast Ohio area***

Name
Email		Phone

• Are you concerned with?

• I have the following condition:

Please tell us about your eyesight:

I will need to finance my correction surgery:	yes no