Cataract Self Test

1

Have you been diagnosed with cataract? * This field is required.

Yes

No

2

What is your age group?* This field is required.

45-50

50-60

Over 60

3

Do you have any health problems that make it risky for you to have cataract surgery? * This field is required.

YESNO

4

Do you need good vision for activities like reading, driving, or playing sports?* This field is required.

YESNO

5

Do you have any other eye problems that might affect how well you can see after cataract surgery? * This field is required.

YESNO

6

Do you have a clear idea of what you can expect from cataract surgery and the lenses you might choose? * This field is required.

YESNO

7

Great. Who should we send the results to? * This field is required.

example@example.com

8

Would you like a courtesy call from one of our experienced medical secretaries to discuss your options?* This field is required.

Yes

No

9

Your Title:

10

Your Name:

First Name

Last Name

11

If you would like us to call you with more information, please insert your number below:

Please enter a valid phone number.

12

How did you hear about us?