{"id":2891,"date":"2022-08-09T18:59:38","date_gmt":"2022-08-09T18:59:38","guid":{"rendered":"https:\/\/eyectexas.com\/?page_id=2891"},"modified":"2023-08-11T19:37:47","modified_gmt":"2023-08-11T19:37:47","slug":"cataract-self-evaluation","status":"publish","type":"page","link":"https:\/\/eyectexas.com\/cataract-fort-worth\/cataract-self-evaluation\/","title":{"rendered":"Cataract Self Evaluation"},"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_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>Complete our cataract surgery questionnaire to learn more about your potential vision correction options and how we may be able to help!<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/wp-json\/wp\/v2\/pages\/2891#gf_3' data-formid='3' novalidate>\n        <div id='gf_progressbar_wrapper_3' 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'>6<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_3_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_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_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_3\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\" ><label class='gfield_label gform-field-label' for='input_3_3'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_3_3' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\" ><label class='gfield_label gform-field-label' for='input_3_4'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_3_4' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_5\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\" ><label class='gfield_label gform-field-label' for='input_3_5'>Do we have consent to text you?<\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_3_5' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' selected='selected'>Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer before'>\n                         <input type='button' id='gform_next_button_3_6' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-6' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_3_7\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_7\" ><legend class='gfield_label gform-field-label' >What is your age group?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_7'>\n\t\t\t<div class='gchoice gchoice_3_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='gquiz708144b9f'  id='choice_3_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_7_0' id='label_3_7_0' class='gform-field-label gform-field-label--type-inline'>Under 18<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='gquiz71c3e4bd5'  id='choice_3_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_7_1' id='label_3_7_1' class='gform-field-label gform-field-label--type-inline'>19-39<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='gquiz77323f92e'  id='choice_3_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_7_2' id='label_3_7_2' class='gform-field-label gform-field-label--type-inline'>40-59<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_7_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='gquiz78e5c3454'  id='choice_3_7_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_7_3' id='label_3_7_3' class='gform-field-label gform-field-label--type-inline'>60+<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_24\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_3_8\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_8\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your vision without glasses (check all that apply):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_8'><div class='gchoice gchoice_3_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='gquiz708144b9f'  id='choice_3_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_1' id='label_3_8_1' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"https:\/\/eyectexas.com\/wp-content\/uploads\/2023\/08\/see-far-s-e1692044911991.png\"> I&#8217;m Farsighted: I have trouble reading and seeing up close.<br \/><br \/><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='gquiz71c3e4bd5'  id='choice_3_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_2' id='label_3_8_2' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"https:\/\/eyectexas.com\/wp-content\/uploads\/2023\/08\/see-near-s-e1692044874364.png\"> I&#8217;m Nearsighted: I have trouble driving and seeing things far away.<br \/><br \/><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='gquiz77323f92e'  id='choice_3_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_3' id='label_3_8_3' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"https:\/\/eyectexas.com\/wp-content\/uploads\/2023\/08\/see-a-s-e1692045198794.png\"> Astigmatism: My vision is distorted, and I generally can&#8217;t see very well.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer before'>\n                        <input type='button' id='gform_previous_button_3_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"1\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"1\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_9' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_3_10\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What do you typically wear (check all that apply):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_10'><div class='gchoice gchoice_3_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='gquiz708144b9f'  id='choice_3_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"https:\/\/eyectexas.com\/wp-content\/uploads\/2023\/08\/wear-glasses-e1692202695560.png\"> Glasses<br \/><br \/><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='gquiz71c3e4bd5'  id='choice_3_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_2' id='label_3_10_2' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"https:\/\/eyectexas.com\/wp-content\/uploads\/2023\/08\/wear-contacts-e1692202850660.png\"> Contacts<br \/><br \/><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='gquiz77323f92e'  id='choice_3_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_3' id='label_3_10_3' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"https:\/\/eyectexas.com\/wp-content\/uploads\/2023\/08\/wear-reading-glasses-e1692202897749.png\"> Reading Glasses<br \/><br \/><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='gquiz10a027a89d'  id='choice_3_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_4' id='label_3_10_4' class='gform-field-label gform-field-label--type-inline'><img decoding=\"async\" src=\"https:\/\/eyectexas.com\/wp-content\/uploads\/2023\/08\/wear-none-e1692202940241.png\"> None of Them<br \/><br \/><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_25\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_3_11\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_11\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any of the following? (Check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_11'><div class='gchoice gchoice_3_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='gquiz708144b9f'  id='choice_3_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>Rheumatoid Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='gquiz71c3e4bd5'  id='choice_3_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_2' id='label_3_11_2' class='gform-field-label gform-field-label--type-inline'>Multiple Sclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='gquiz77323f92e'  id='choice_3_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_3' id='label_3_11_3' class='gform-field-label gform-field-label--type-inline'>Lupus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='gquiz10a027a89d'  id='choice_3_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_4' id='label_3_11_4' class='gform-field-label gform-field-label--type-inline'>Cataracts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='gquiz1151715ae7'  id='choice_3_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_5' id='label_3_11_5' class='gform-field-label gform-field-label--type-inline'>Keratoconus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='gquiz112c0a659f'  id='choice_3_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_6' id='label_3_11_6' class='gform-field-label gform-field-label--type-inline'>Diabetic Retinopathy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.7' type='checkbox'  value='gquiz11005e8197'  id='choice_3_11_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_7' id='label_3_11_7' class='gform-field-label gform-field-label--type-inline'>Prior serious eye injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.8' type='checkbox'  value='gquiz113f97abf1'  id='choice_3_11_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_8' id='label_3_11_8' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer before'>\n                        <input type='button' id='gform_previous_button_3_12' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_12' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-12' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_3_13\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_13\" ><legend class='gfield_label gform-field-label' >Have you been told you have cataracts and need surgery?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_13'>\n\t\t\t<div class='gchoice gchoice_3_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='gquiz13740bc5a3'  id='choice_3_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_13_0' id='label_3_13_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_3_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='gquiz1374ccee21'  id='choice_3_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer before'>\n                        <input type='button' id='gform_previous_button_3_14' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_14' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' data-js='page-field-id-14' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_3_23\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\" ><\/div><fieldset id=\"field_3_17\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_17\" ><legend class='gfield_label gform-field-label' >I would like to see well at a distance without relying on glasses and contact lenses.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_17'>\n\t\t\t<div class='gchoice gchoice_3_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='gquiz1787ced8ea'  id='choice_3_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_17_0' id='label_3_17_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_3_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='gquiz17c82916e3'  id='choice_3_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_17_1' id='label_3_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='gquiz17b723cb9f'  id='choice_3_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_17_2' id='label_3_17_2' class='gform-field-label gform-field-label--type-inline'>I&#8217;m not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_18\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_18\" ><legend class='gfield_label gform-field-label' >I would like to see well up close without relying on glasses and contact lenses.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_18'>\n\t\t\t<div class='gchoice gchoice_3_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='gquiz1787ced8ea'  id='choice_3_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_18_0' id='label_3_18_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_3_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='gquiz17c82916e3'  id='choice_3_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_18_1' id='label_3_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='gquiz17b723cb9f'  id='choice_3_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_18_2' id='label_3_18_2' class='gform-field-label gform-field-label--type-inline'>I&#8217;m not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_19\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_19\" ><legend class='gfield_label gform-field-label' >It&#039;s important to me to see well at night after cataract surgery.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_19'>\n\t\t\t<div class='gchoice gchoice_3_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='gquiz1787ced8ea'  id='choice_3_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_19_0' id='label_3_19_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_3_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='gquiz17c82916e3'  id='choice_3_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_19_1' id='label_3_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='gquiz17b723cb9f'  id='choice_3_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_19_2' id='label_3_19_2' class='gform-field-label gform-field-label--type-inline'>I&#8217;m not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer before'>\n                        <input type='button' id='gform_previous_button_3_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_20' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_6' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_3_21\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which of the following do you most want to do without depending on glasses after cataract surgery? (Check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_21'><div class='gchoice gchoice_3_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='gquiz21afc78878'  id='choice_3_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_1' id='label_3_21_1' class='gform-field-label gform-field-label--type-inline'>Seeing Far Away (TV, night driving, golfing)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='gquiz218d3c4995'  id='choice_3_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_2' id='label_3_21_2' class='gform-field-label gform-field-label--type-inline'>Seeing Intermediate Distances (computer, cooking, iPad)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='gquiz219c1decb0'  id='choice_3_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_3' id='label_3_21_3' class='gform-field-label gform-field-label--type-inline'>Seeing Up Close (Newsprint, maps, books)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='gquiz2153630239'  id='choice_3_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_4' id='label_3_21_4' class='gform-field-label gform-field-label--type-inline'>Seeing Very Close (puzzles, embroidery, sewing and other crafting<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_3_22\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" data-js-reload=\"field_3_22\" ><legend class='gfield_label gform-field-label' >Would you like to speak with our Laser Vision Correction Team?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_22'>\n\t\t\t<div class='gchoice gchoice_3_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='gquiz2225d9b9c5'  id='choice_3_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_0' id='label_3_22_0' class='gform-field-label gform-field-label--type-inline'>I&#8217;m ready to book my consultation!<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='gquiz22dd4bd3a9'  id='choice_3_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>Yes, please call me to discuss my options.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='gquiz220a4e2a0b'  id='choice_3_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_2' id='label_3_22_2' class='gform-field-label gform-field-label--type-inline'>I&#8217;m not ready yet.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform_page_footer before'><input type='submit' id='gform_previous_button_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_3\"]){return false;}  if( !jQuery(\"#gform_3\")[0].checkValidity || 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