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Contact Us

Contact Us for More Information

We are here to answer your questions and ease your concerns. Feel free to complete the form below. Thanks for your interest, and we look forward to improving your vision.

 This form just takes a moment to use.
Name: (Required)
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Email: (Required)

Age:

Health insurance or Vision insurance provider:

Male Female

 

What type of contacts do you wear: 

 

 

 

 

 

 

How did you hear about us:

Glasses only

Soft contacts-not slept in

Soft contacts-slept in

Torique lens-slept in or not

Hard contacts or RGP- slept in or not

 

 
Are you interested in
(check all that apply):
Attending a free seminar
Scheduling a complimentary consultation
Having information mailed to your home address
Applying for financing
Other
   

What should we know about you?

This is not a secure contact form. Please do not include sensitive medical information in your appointment request that you would not normally feel comfortable sending over email.

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VISIT US AT: 574 Lone Tree Drive, Mount Pleasant, South Carolina 29464
PH: 843-856-5275 | 888-LASIK-36 | FAX: 843-856-8953
EMAIL: sara@charlestoncornea.com