{"id":105,"date":"2016-12-08T17:12:57","date_gmt":"2016-12-08T17:12:57","guid":{"rendered":"http:\/\/demo.eyectexas.com.php56-22.dfw3-1.websitetestlink.com\/?page_id=105"},"modified":"2023-08-15T21:49:05","modified_gmt":"2023-08-15T21:49:05","slug":"lasik-self-evaluation-test","status":"publish","type":"page","link":"https:\/\/eyectexas.com\/lasik-texas\/lasik-self-evaluation-test\/","title":{"rendered":"LASIK Self Evaluation Test"},"content":{"rendered":"<script type=\"text\/javascript\">var 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var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/105#gf_4' data-formid='4' novalidate>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_4_12\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_12\" ><h3 class=\"gsection_title\">Contact Details<\/h3><\/div><fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_2\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_2\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_4_2_container'>\n                                <span id='input_4_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_4_2' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_2' id='input_4_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_4_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_4_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_4_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_4_3\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_3\" ><label class='gfield_label gform-field-label' for='input_4_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_4_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_4_9' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"2\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"2\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_2' class='gform_fields top_label form_sublabel_above description_below'><fieldset id=\"field_4_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_26\" ><legend class='gfield_label gform-field-label' >Have you had eye surgery before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_26'>\n\t\t\t<div class='gchoice gchoice_4_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_4_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_26_0' id='label_4_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_4_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_26_1' id='label_4_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_27\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_27\" ><label class='gfield_label gform-field-label' for='input_4_27'>If yes: Please list the following for up to three (3) of you most recent eye surgeries.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_4_27' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_36\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_36\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_29\" ><legend class='gfield_label gform-field-label' >Would you be interested in other treatment options if you are not a LASIK candidate?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_29'>\n\t\t\t<div class='gchoice gchoice_4_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_4_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_29_0' id='label_4_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_4_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_29_1' id='label_4_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_37\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_37\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_30\" ><legend class='gfield_label gform-field-label' >Do you have trouble seeing far away or up close?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_30'>\n\t\t\t<div class='gchoice gchoice_4_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Up close'  id='choice_4_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_30_0' id='label_4_30_0' class='gform-field-label gform-field-label--type-inline'>Up close<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Far away'  id='choice_4_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_30_1' id='label_4_30_1' class='gform-field-label gform-field-label--type-inline'>Far away<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_38\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_38\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_31\" ><legend class='gfield_label gform-field-label' >How interested are you in being able to play sports without glasses and contacts?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_31'>\n\t\t\t<div class='gchoice gchoice_4_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='It&#039;s very important to me NOT to wear glasses for activities such as sports.'  id='choice_4_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_31_0' id='label_4_31_0' class='gform-field-label gform-field-label--type-inline'>It&#8217;s very important to me NOT to wear glasses for activities such as sports.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='It&#039;s not important to me. I do not mind wearing glasses.'  id='choice_4_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_31_1' id='label_4_31_1' class='gform-field-label gform-field-label--type-inline'>It&#8217;s not important to me. I do not mind wearing glasses.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_39\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_39\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_32\" ><legend class='gfield_label gform-field-label' >What is your age?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_32'>\n\t\t\t<div class='gchoice gchoice_4_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Under 21'  id='choice_4_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_32_0' id='label_4_32_0' class='gform-field-label gform-field-label--type-inline'>Under 21<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='21 - 40'  id='choice_4_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_32_1' id='label_4_32_1' class='gform-field-label gform-field-label--type-inline'>21 &#8211; 40<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='40 - 69'  id='choice_4_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_32_2' id='label_4_32_2' class='gform-field-label gform-field-label--type-inline'>40 &#8211; 69<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='69+'  id='choice_4_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_32_3' id='label_4_32_3' class='gform-field-label gform-field-label--type-inline'>69+<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_40\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_40\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_33\" ><legend class='gfield_label gform-field-label' >Are you interested in seeing well up close (reading) without glasses?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_33'>\n\t\t\t<div class='gchoice gchoice_4_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='It&#039;s very important to me NOT to wear reading glasses.'  id='choice_4_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_33_0' id='label_4_33_0' class='gform-field-label gform-field-label--type-inline'>It&#8217;s very important to me NOT to wear reading glasses.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='It&#039;s not important to me. 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