LASIK Self Test

1

SightMD

SightMD

3

Which do you most often wear?* This field is required.

Glasses

Contacts

Both

Neither

4

Without your corrective lens, do you have..* This field is required.

Trouble seeing far away

Trouble seeing up close

Overall blurry vision

Trouble with reading only

5

Have you ever been told that you have astigmatism?* This field is required.

Yes

No

Not Sure

6

Would you consider yourself to be generally healthy?* This field is required.

YESNO

8

When choosing your vision correction, which matters most to you?* This field is required.(check all that apply)

Affordability

Safety

Experience of the Doctor

Compassionate Care

Lifetime Guarantee

Weekend Availability

9

Ideally when were you hoping to have LASIK* This field is required.

ASAP

Next 6 Months

Someday

10

Which Practice are you looking to visit* This field is required.

SightMD New York

SightMD New Jersey

SightMD Pennsylvania

SightMD Connecticut

11

Which SightMD New Jersey location is closest to you?* This field is required.

Barnegat

Toms River

Brick

Spring Lake Heights

13

Which SightMD Pennsylvania location is closest to you?* This field is required.

Elkins Park

Philadelphia

Pottsville

Shamokin

Wyomissing

15

Name* This field is required.

First Name

Last Name

16

Email* This field is required.

example@example.com

17

Phone Number* This field is required.

18

Do you consent to receive SMS messages from SightMD regarding your appointments, treatment, and other important updates?* This field is required.

YESNO

19

Please verify that you are human* This field is required.