LASIK / PRK Candidacy

Check if you are a LASIK or PRK candidate

Share a short medical and lifestyle snapshot. Dr. Roxanna Gangi personally reviews each request and reaches out with the most appropriate next step. This form is not a medical evaluation and does not guarantee surgical candidacy.

About you

Full name *

Age *

Email *

Phone *

Preferred contact method *

Address (optional — start typing to auto-fill city and postal code)

City or postal code *

Preferred clinic location *

Eye history

Current prescription (if known) *

Has your prescription been stable for 12+ months? *

Contact lens use

Dry Eye Diseases *

Have you ever been told you are NOT a candidate? *

Timing & next steps

When would you ideally like to have surgery? *

Are you interested in financing options for the costs of your surgery? *

Preferred consultation type *

Have you already contacted a surgical centre? *

Optional upload & notes

Upload your most recent prescription (optional, max 10 MB)

Choose file

Anything else Dr. Roxanna Gangi should know? (optional)

I understand this form is a candidacy inquiry, not a medical evaluation, and that final suitability for LASIK or PRK requires an in-person assessment by Dr. Roxanna Gangi or a qualified surgical team. I consent to being contacted by Pro Eye Exam regarding this request.

Your information is reviewed privately by Dr. Roxanna Gangi's team.