Refractive Surgery Candidacy Quiz

Refractive Surgery Candidacy Quiz
This short refractive surgery candidacy quiz will not only give you information about whether or not you are a candidate, but also which refractive procedure is best for you. Please answer the following questions to the best of your knowledge. Good luck!
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Which is your age group?

18-34 35-55 55-70 70+
Check all that apply:

I wear glasses for distance I wear contacts for distance I wear reading glasses I wear multifocals (bifocals) I don’t wear any corrective lenses
Which best describes your visual condition

I am nearsighted (need help seeing far away) I am farsighted (need help seeing up close) I am presbyopic (need help seeing far and up close) I have astigmatism (distortion at all distances) None of the above
If you know your glasses or contact lens prescription please enter it here:
Tell us about your health. Check all that apply to you

Rheumatoid Arthritis Lupus Multiple Sclerosis Keratoconus Diabetic Retinopathy Pregnant or Nursing Cataracts Glaucoma Previous Eye Surgery Serious Eye Injury Other Auto-Immune Disease
How would you describe your general health

Extremely Healthy Healthy for the most part Slightly unhealthy but nothing major Very unhealthy
Are you being treated for dry-eye syndrome or ever been told you have severe dry eyes?

Yes No
Rank the importance of the following statement: “When it comes to refractive surgery, cost is my primary concern.”

1

2

3

4

5

1 is Not At All, 5 is Absolutely Yes
Rate the importance of this statement: “Reversibility is very important to me with regards to eye surgery.”

1

2

3

4

5

1 is Not At All, 5 is Absolutely Yes
Rate the importance of this statement: “The newest technology and the latest approved procedures are what I want.”

1

2

3

4

5

1 is No, 5 is Yes
At Standard Optical we offer several refractive surgery options. Our professional optometry and surgical staff will make the recommendation that they see fit. Which of the following procedures are you interested in having or learning more about. (Click all that apply)

Custom All Laser iLASIK PRK (Laser treatment without a flap) Visian ICL (Implantable Contact Lens) RLE (Refractive Lens Exchange) SMILE Premium Cataract Implant
When would you be interested in having refractive surgery?

Within a month 2-3 months from now In 6+ months In 12 months I’m not sure
Many health insurance plans offer a discount on refractive surgery, which health insurance plan do you have?
Would you like information regarding free financing options?

Yes No
Are there multiple people in your family, work or friend group that would be interested in refractive surgery?

Yes No
If you answered yes to the above question, would you be interested in a special discount for multiple patients?

Yes No
By checking the box below you are giving consent to Standard Optical to send you materials regarding your answers to this quiz as well as consent to contact you electronically, via mail or via phone to discuss your options and answer questions. Please check:

Yes I agree No I don’t agree
Should be Empty: