Ennen LASIK Self-Evaluation

1

Select your age group* This field is required.

21-50

51+

2

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

Far Away

Up Close

Both

3

Do you have astigmatism?* This field is required.

Yes

No

Not Sure

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

Have you ever had an eye injury or eye surgery?* This field is required.

YESNO

7

Have you been told you have any of the following?* This field is required.

Diabetic Retinopathy

Keratoconus

Lupus

Rheumatoid Arthritis

Amblyopia (one eye weaker than the other)

None/Not Mentioned

8

Are you currently, or have been pregnant or nursing within the last 6 months?* This field is required.

Yes

No

N/A

9

What is your main reason for wanting LASIK?* This field is required.Please select one.

Convenience

Improve my active lifestyle

Appearance

Better vision in general

For my occupation

Other

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.*By submitting, you authorize Ennen Eye Center to text and call the number you provided with information, possibly using automated means. Msg & data rates may apply. Consent is not a condition of purchase. You may always reply STOP to cancel text messages. Msg frequency varies.

YESNO

15

Which type of communication would you prefer from us?

Text

Call

Email

16

Our system requires us to enter your date of birth to begin text communication. Please enter that below. mm/dd/yyyy

17

Service

18

Source

19