Refractive Surgery Candidacy Quiz

$Refractive Surgery Candidacy Quiz$

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 NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Which is your age group?
Check all that apply:
Which best describes your visual condition
If you know your glasses or contact lens prescription please enter it here:
Tell us about your health. Check all that apply to you
How would you describe your general health
Are you being treated for dry-eye syndrome or ever been told you have severe dry eyes?
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

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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)
When would you be interested in having refractive surgery?
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?
Are there multiple people in your family, work or friend group that would be interested in refractive surgery?
If you answered yes to the above question, would you be interested in a special discount for multiple patients?
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:
Should be Empty: