Lasik Self Test

First Name*
Last Name*
Phone*
Email*
Do we have consent to text you?*

What is your age group?*

Under 1819-3940-5960+

Without my glasses and contacts... (Check All That Apply)*

What do you usually wear? (Check All That Apply)*

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

Rate this statement on a scale of 1 to 5 with 1 being the lowest.
I would like to see well at a distance without relying on glasses and contact lenses.*

12345

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

Rate this statement on a scale of 1 to 5 with 1 being the lowest.
I would like to see well at a distance without relying on glasses and contact lenses.*

12345

Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?
Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?*

YesNo

Are you ready to schedule a consultation?*

Yes, I'm ready to scheduleI want more informationNo, I'm not ready to schedule
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