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Under 45 LASIK Self-Evaluation
Please take a minute to complete our quiz and we will call you to discuss your individual vision correction options.
11
Questions
START
HIPAA
Compliance
1
Without correction, do you have trouble seeing:
*
This field is required.
Correction includes any eyeglasses or contact lenses.
Up Close
Far Away
Both
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2
Which do you use most frequently?
*
This field is required.
Prescription Glasses
Contact Lenses
Over the Counter Readers
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3
Do you need brighter light for reading?
*
This field is required.
YES
NO
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4
Which best reflects your primary reason for wanting LASIK surgery?
*
This field is required.
Please select one.
I have an active or busy lifestyle.
I look better without glasses.
I do not like wearing contacts.
I am too dependent on my glasses.
I am too dependent on my contacts.
My career would improve with LASIK.
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5
What is your primary concern with LASIK?
*
This field is required.
Affordability
The skill of my surgeon
Safety
Recovery time
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6
Have you been told you have any of the following?
*
This field is required.
Rheumatoid Arthritis
Lupus
Prior Eye Surgery
Currently Pregnant
Diabetic Retinopathy
Prior Serious Eye Injury
Karatoconus
None/Not Mentioned
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7
Have you been told you have any of the following Hidden
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8
What is your full name?
*
This field is required.
First Name
Last Name
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9
What is your email?
*
This field is required.
example@example.com
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10
What is your mobile number?
*
This field is required.
We will call you to discuss the options based on your quiz submissions.
Please enter a valid phone number.
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11
Do we have permission to text you?
*
This field is required.
We need your permission in order to use this way of communication to answer questions, help you schedule appointments and confirm appointments.
YES
NO
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12
Which form of communication do you prefer?
Text
Call
Email
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13
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14
Source
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