inner

Name(Required)

First Last

Phone

Email

Do we have consent to text you?

What is your age group?

Under 18

19-39

40-59

60+

Your vision without glasses (check all that apply):

I’m Farsighted: I have trouble reading and seeing up close.

I’m Nearsighted: I have trouble driving and seeing things far away.

Astigmatism: My vision is distorted, and I generally can’t see very well.

Have you been told you have cataracts and need surgery?

Yes

No

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

Yes

No

I’m not sure

I would like to see well up close without relying on glasses and contact lenses.

Yes

No

I’m not sure

It's important to me to see well at night after cataract surgery.

Yes

No

I’m not sure

Which of the following do you most want to do without depending on glasses after cataract surgery? (Check all that apply)

Seeing Far Away (TV, night driving, golfing)

Seeing Intermediate Distances (computer, cooking, iPad)

Seeing Up Close (Newsprint, maps, books)

Seeing Very Close (puzzles, embroidery, sewing and other crafting

Would you like to speak with our Laser Vision Correction Team?

I’m ready to book my consultation!

Yes, please call me to discuss my options.

I’m not ready yet.

Cataract Self Evaluation