Contact Us

Please fill out this contact form below as completely as possible to receive all of the following
valuable benefits:

Upon REQUEST during your Free Consultation at Park Avenue Laser Vision, we will give you the following (please remember to ASK us if you want any item):

• Free Internet consultation and immediate reply from Dr.Chynn himself!
• Free DVD about LASEK & EPI-LASEK when you come in for your free consult!
• Free digital photograph of your eyes emailed to you!
• Free Customvue Wavefront given to you -- a fingerprint of your individual eyes!
• Free gift bag!

Name:

Enter your name here

*
e-mail Address:

You Must Provide a Valid Email.

*
Age:

So we can recommend the correct procedure for your age.

DayTime Phone:

Country: United States Canada Mexico United Kingdom Ireland France Italy Denmark Russia Belgium Netherlands Greece Turkey Israel Monaco Switzerland Sweden Germany Japan Singapore China - Hong Kong Korea Malaysia Brazil Colombia Carribean Islands Peru Argentina Other
Sex: Female Male
Prefered Method of Contact: Phone Fax Email
Contact Lens Use: none soft daily wear soft daily disposable soft frequent replacement soft extended wear hard/RGP
Occupation:

To tailor your procedure to your visual needs!

Medical Health Insurance:

Your medical (not vision) insurance, so we can offer you an insurance discount!.

Company/Employer:

So we can offer you a corporate discount!

left Eye Prescription:

Give an approximation: (glasses/contacts, include the +/- sign, i.e., -3.50)

Right Eye Prescription:

Give an approximation: (glasses/contacts, include the +/- sign, i.e., -3.50)

What is the main reason you are seeking Laser Vision Correction?
What are your major concerns about Laser Vision Correction?
Do you have any other eye conditions you want Dr. Chynn to know about?