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VIP LASIK Evaluation

Schedual your FREE VIP LASIK evaluation today by filling out the online form below. Our office will contact you to verify your request. If you have any questions, please call 806-353-0125.

NAME:first/last	*
ADDRESS:
TELEPHONE: h/w	*
CITY / STATE:
ZIP CODE:
EMAIL ADDRESS:	*

Requested Time:
Requested Day:
QUESTIONS:

*Your information will not be disclosed for any purposes other than to use to schedule an appointment with Dr. Avery Rush.