1. How old are you? +
2. You have difficulty seeing near, far,or both? +
3.What type of corrective lenses do you wear, if any? +
4. How would your life be improved by good vision? +
5. What kind of work do you do? +
6. What hobbies and activities are important to you? +
7. If you prefer, our counselor could call, email, or mail information to you. We do not distribute or sell addresses, email addresses, or phone numbers. When is the best time to call, or would you prefer a different method? +
8. General Info +
Name: +
Phone: +
E-Mail: +
Address: +
State: +
Zip: +
9. Have you been told that you are a candidate for LASIK surgery? +
10. If you have been told that you are not a candidate for LASIK, would you like to hear about other possible options? +
11. Many patients tell us that deciding on vision correction surgery is a process. Where would you say you are in the decision making process? +
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