Berkeley Eye Center | Your Vision Partner in Houston

1

Select your age group* This field is required.

45–64

65+

2

How long has it been since your last eye exam?* This field is required.

Within 12 months

1–2 years

2–5 years

More than 5 years

3

Has it become more difficult to read and see objects up close?* This field is required.

Yes

No

4

Do you have difficulty seeing objects at a distance?* This field is required.

Yes

No

5

Are you seeing glare when driving at night?* This field is required.

Yes

No

6

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

Yes

No

7

What is most important to you?* This field is required.

Affordable treatment

Skill of my surgeon

Having treatment right away

Achieving best vision possible

Potential to read without glasses

Potential to drive without glasses

8

Have you been told you have any of the following conditions?

9

First & Last Name* This field is required.

First Name

Last Name

10

Phone NumberEntering your phone number authorizes Berkeley Eye Center to call you.

Please enter a valid phone number.

11

Text Message Opt InDo you authorize Berkeley Eye Center to text you. Message/data rates apply.

Yes

No

12

Email* This field is required.

example@example.com

13

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