First Name(Required)

Last Name(Required)

Phone(Required)

Email

Can We Text You?(Required)

Yes

No

What is your age group?

Under 18

19-39

40-59

60+

Without my glasses and contacts... (check all that apply)

Farsightedness: I have trouble reading and seeing things up close‎

Nearsightedness: I have trouble driving and seeing things far away‎

Astigmatism: I have distorted vision and cannot see very well‎

What do you usually wear? (check all that apply)(Required)

Glasses‎

Contacts‎

Reading Glasses‎

None of Them‎

Do you have any of the following? (check all that apply)(Required)

Rheumatoid Arthritis‎

Multiple Sclerosis‎

Lupus‎

Cataracts‎

Keratoconus‎

Diabetic Retinopathy‎

Prior Eye Surgery‎

Prior serious eye injury‎

None of the above‎

Have you been told you have cataracts and require surgery?

Yes

No

I would like to see well at a distance without relying on glasses and contact lenses.(Required)

Yes

No

I'm not sure

I would like to see well up close without relying on glasses and contact lenses.(Required)

Yes

No

I'm not sure

It is important to me to see well at night after cataract surgery.(Required)

Yes

No

I'm not sure

Think about the things in life you want to do without depending on glasses after cataract surgery. Which group is the most important? (check all that apply)(Required)

Seeing Far Away (TV, night driving, golfing)‎

Seeing Intermediate Distances (Computer, cooking, iPad)‎Second Choice

Seeing Close Up (Newsprint, maps, books)‎

Seeing Very Close (Embroidery, sewing and other crafting, puzzles)‎

Would you like to speak with our Laser Vision Correction Team?

I'm ready to book my consultation!

Yes, please call me to discuss my options.

I'm not ready yet

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