1. What is your age group?

Under 18

19-39

40-59

60+

2. Without my glasses and contacts... (check all that apply)

Farsightedness : Difficulty reading and seeing things up close

Nearsightedness : Difficulty driving and seeing things far away

Astigmatism : Distorted vision and cannot see very well in general

3. What do you usually wear? (check all that apply)

4. Do you have any of the following? (check all that apply)

5. I would like to see well at a distance without relying on glasses and contact lenses.

Rate this statement on a scale of 1 to 5 with 1 being the lowest.

6. I would like to see well up close without relying on glasses or contacts.

Rate this statement on a scale of 1 to 5, with 1 being the lowest.

7. Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?

8. Would you like to speak with our laser vision correction team?

How Should We Contact You?

This is how we will contact you to go over your results and schedule a complementary consultation.

Can we text you?