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Over 45 Self-Evaluation
Please take a minute to complete our quiz and we will call you to discuss your individual vision correction options.
13
Questions
START
HIPAA
Compliance
1
Select your age group
*
This field is required.
45-64
65+
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2
Have you ever been told you have cataracts?
*
This field is required.
YES
NO
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3
How long has it been since your last eye exam?
*
This field is required.
Please select one.
Within 12 months
1-2 years
2-5 years
More than 5 years
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4
Are you seeing glare when driving at night?
*
This field is required.
YES
NO
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5
Has it become difficult to read and see objects up close?
*
This field is required.
YES
NO
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6
Do you have difficulty seeing objects at a distance?
*
This field is required.
YES
NO
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7
What is most important to you?
*
This field is required.
Select one.
Affordability
The skill of my surgeon
Having surgery right away
Achieving best vision possible
Potential to read without glasses
Potential to drive without glasses
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8
Do you have any of the following?
*
This field is required.
Select all that apply.
Rheumatoid Arthritis
Lupus
Prior Eye Surgery
Currently Pregnant
Diabetic Retinopathy
Prior Serious Eye Injury
Karatoconus
None/Not Mentioned
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9
What is your full name?
*
This field is required.
First Name
Last Name
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10
What is your email?
*
This field is required.
example@example.com
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11
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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12
Do we have permission to text you?
*
This field is required.
While we are not yet using text-based communications, we would like your permission for the future.
YES
NO
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13
Which do you prefer for communication with us?
Text
Call
Email
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14
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