Name:
Email address:
Phone Number:

What made you decide to have laser vision correction?


What did you like most about your experience with Nationwide Vision LASIK surgery?


Additional Comments or Suggestions:


I give permission to Nationwide Vision to use my comments and name in promotioinal materials regarding the Laser & Eye Center and LASIK surgery
Yes       No

I am willing to talk about future patients about my LASIK experience success.
Yes       No