Contact Us

Please Fill Out the Following from COMPLETELY, as the staff of Park AVenue Laser Vision will be getting this form back, INCLUDING DR. CHYNN, and they cannot give you accurate advice about your situation unless they know this information. You will receive a Personal Recommendation from Dr. Chynn himself about which procedure is right for you given your age, occupation, and special concerns. Additionally you will 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.

Phone Number

Enter your ten digit phone number (include area code, no spaces or slashes)

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 Insurance:

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

Employer:

So we can offer you a corporate discount!

Right Eye Prescription:

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

Left 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?