LASIK Self-Evaluation

1
What is your age group?* This field is required.
Under 18
18 - 40
41 - 55
Over 55
2
Please provide your Date of Birth* This field is required.
Date
Month
Day
Year
3
Do you have trouble seeing far away or up close?* This field is required.
Far Away
Up Close
Both
4
Which areas of your life would be improved with better vision?* This field is required.
Career
Sports
Social Life
Recreational Activities
Other
5
If you are a candidate, how soon would you like to improve your vision?* This field is required.
As soon as possible
In the next few weeks
In the next few months
In the next year
6
Are you interested in financing options?* This field is required.
Yes
No
Maybe
7
How did you hear about LASIK at Empire Eye and Laser Center?* This field is required.
Facebook
Instagram
Google Search
Print Ad
Referred by my Optometrist
Referred by family/friend
Word of Mouth
Other
8
What is your name?* This field is required.
First Name
Last Name
9
Where can we email you about your results?* This field is required.
example@example.com
10
Where can we contact you about your results?* This field is required.
Please enter a valid phone number.
11
Please verify that you are human* This field is required.
12
13
Tags
Todo
In Progress
Done
Should be Empty: