CW LASIK Self-Evaluation

1

Select your age group* This field is required.

18-55

56+

2

Without correction, do you have trouble seeing:* This field is required.Correction includes any eyeglasses or contact lenses.

Up Close

Far Away

Both

3

Do you have astigmatism?* This field is required.

Yes

No

Unknown

4

Which do you use most frequently?* This field is required.

Prescription Glasses

Contact Lenses

Reading Glasses

5

If you wear reading glasses, are you interested in seeing well up close without them?* This field is required.

YES, I would prefer not to wear reading glasses.

NO, I don't wear reading glasses or don't mind them.

6

Do you need brighter light for reading?* This field is required.

YESNO

7

Have you ever been told you have cataracts?

YESNO

9

Which best reflects your primary reason for wanting LASIK?* This field is required.Please select one.

I have an active or busy lifestyle.

I look better without glasses.

I do not like wearing contacts.

I am too dependent on my glasses.

I am too dependent on my contacts.

My career would improve with LASIK.

10

What is your primary concern with LASIK?* This field is required.

Affordability

The skill of my surgeon

Safety

Convenience

11

What is your full name?* This field is required.

First Name

Last Name

12

What is your email?* This field is required.

example@example.com

13

What is your mobile number?* This field is required.We will call you to discuss the options based on your quiz submissions.

Please enter a valid phone number.

14

Do we have permission to text you?* This field is required.While we are not yet using text-based communications, we would like your permission for the future.

YESNO

15

Which type of communication would you prefer from us?

Text

Call

Email

16