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I N F O R E Q U E S T
Please fill out the following
information to receive a LASIK packet in the mail.
Name:
Address:
City
State
Zip
Daytime phone number:
E-mail address:
Occupation:
Age group:
20-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71+
What (day)
and (time)
is best for you for your free evaluation?
How did you hear about
Michigan Eyecare Institute?
What are your greatest
concerns regarding LASIK?
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