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How Did You Hear About Us?
How Did You Hear About Us?
Radio station KJKK 100.3
Radio station KTCK 1310/96.7
Radio station KSCS 96.3
Radio station KMVK 107.5
Radio station KRLD 105.3
Radio station KLTY-FM 94.9
BOGO sign
Yelp
Facebook
Google search
Friend/Family
Physician
Insurance
Drive-By
Instagram
Other
Do we have permission to text you?
Yes
No
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1
What is your age group?
What is your age group?
Under 18
19-39
40-59
60+
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2
Without my glasses and contacts... (Check All That Apply)
Without my glasses and contacts
Farsightedness : I have trouble reading and seeing things up close
Nearsightedness : I have trouble driving and seeing things far away
Astigmatism : I have distorted vision and cannot see very well
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3
What do you usually wear? (Check All That Apply)
What do you usually wear?
Glasses
Contacts
Reading Glasses
None of Them
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4
Would your lifestyle improve if you were to become less dependent on glasses and contact lenses?
Would your career or business activities improve if you were to become less dependent on glasses and contacts?
Yes
No
Test Score
SUBMIT