Laser Vision Correction Screening - Richmond Eye Associates


Right Eye Glasses Prescription Be sure to include plus (+) and minus (-) signs as they are on the prescription. (Click here to see some examples of prescriptions)

	Sphere (sph):	Cylinder (cyl):	Axis:	Add (bifocal):

Does the prescription indicate that any "prism" is present for the right eye? Yes: No:


Left Eye Glasses Prescription Be sure to include plus (+) and minus (-) signs as they are on the prescription. (Click here to see some examples of prescriptions)

	Sphere (sph):	Cylinder (cyl):	Axis:	Add (bifocal):

Does the prescription indicate that any "prism" is present for the left eye? Yes: No:


Which of the following best describes how you correct your near vision, such as reading the newspaper, doing close hand work, or using a computer?
	I can see at near with or without glasses, and the glasses are not bifocals.
	I use bifocals, trifocals, or separate reading glasses.
	I usually remove my glasses to see at near, but I can read with them on also.
	I cannot see at near without removing my glasses.



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Laser Vision Correction Screening Evaluation
CustomVue™ Lasik