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How Did You Hear About Us?
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Building Sign/Drive By
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Co-Manage Optometrist
Facebook
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Previous Patient
Radio Station KBOC 98.3 Luna
Radio Station KDMX 102.9 The Mix
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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
5
Would you like to speak with our Laser Vision Correction Team?
5
Would you like to speak with our Laser Vision Correction Team?
Would you like to speak with our Laser Vision Correction Team?
I'm ready to book my consultation!
Yes, please call me to discuss my options.
I'm not ready yet.
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