Berkeley Eye Center | A Cataract Partner You Can Trust

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

What type of activities are most important to you without having the need for glasses?

6

If you had to wear glasses after your vision treatment, which one would you mind less?* This field is required.

Wearing reading glasses to see things up close.

Wearing glasses for driving and other activities that require seeing at a distance.

7

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

8

First & Last Name* This field is required.

First Name

Last Name

9

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

Please enter a valid phone number.

10

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

Yes

No

11

Email* This field is required.

example@example.com

12

Would you like to be contacted as soon as possible to set up an eye exam?* This field is required.

Yes

No