Pacific Laser Eye Centre

Candidacy form

Please fill out the form below. We will use this information to contact you and determine your candidacy

Last Name:

First Name:

DOB

Email Address:

Phone Number:

Address:

Glasses prescription:

Please upload a photo of your glasses prescription. If you do not have a personal copy, please contact your optometrist to provide it for you or fax directly to our clinic at 604-736-2699.

Contact Lens prescription: (If applicable)

If applicable, please upload a photo of your contact lens prescription/box. This is usually different from your glasses prescription. Please make sure the image captures information on BC (base curve) and DIA (diameter)

Have you ever had any previous eye surgeries?

(If yes, please elaborate below)

Yes

Comments:

Once we receive this information we will pass it along to our technicians for review and will be in touch regarding your candidacy, quote, and our clinic’s availability for procedure dates.

Phone:

604-736-2625

Fax:

604-736-2699

Open

Mon - Fri 9am to 5pm

Candidacy form