Clone of Center For Sight LASIK Self-Evaluation

1

Select your age group* This field is required.

19-55

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

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

None/Not Mentioned

8

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

9

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

Affordability

The skill of my surgeon

Safety

Convenience

10

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

First Name

Last Name

11

What is your email?* This field is required.

example@example.com

12

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. By submitting this form. you authorize Talley Eye to text, call and/or email you. Message/data rates apply.

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