First Name
*
Last Name
*
Phone
*
Email
*
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What is your age group?
*
Under 18
19-39
40-59
60+
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Without my glasses and contacts...
Check all that apply
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What do you usually wear?
*
Glasses
Contacts
Reading Glasses
None of the above
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Do you have any of the following
*
Cataracts
Keratoconus
Glaucoma
Lupus
Multiple Sclerosis
Rheumatoid Arthritis
Prior vision correction surgery
Prior eye injury
Are you pregnant or nursing?
None of these
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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.
*
1
2
3
4
5
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I would like to see well up close without relying on glasses and contact lenses.
Rate this statement on a scale of 1 to 5 with 1 being the lowest.
*
1
2
3
4
5
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What is your biggest concern with Laser Vision Correction?
Affordability
Safety
Experience of Surgeon
Recovery Time
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