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1
What is your age group?
What is your age group?
19-39
40-59
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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
Do you have any of the following? (Check All That Apply)
Do you have any of the following?
Dry Eyes
Keratoconus
Glaucoma
Macular Degeneration
None of the above
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5
Why do you want your vision corrected?
Why do you want your vision corrected?
I want visual freedom to improve my lifestyle
I want to save money over time
Tired of the hassle of glasses and contacts
All of the above
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6
Which of the following are important to you?
Which of the following are important to you?
I want to meet the surgeon who will perform the procedure
I want to know my options beyond LASIK
I want to know about the affordably of LASIK
I want to know about the technology that is used
All of the above
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7
Like any medical procedure there are risks associated with LASIK vision correction. Are you willing to discuss these risks with our staff
at a Free Screening
?
Like any medical procedure there are risks associated with LASIK vision correction. Are you willing to discuss these risks with our staff?
Yes
No
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8
What are you looking for in a surgeon?
What are you looking for in a surgeon?
Experience
Safety
Competence & Solid Outcomes
All of the above
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9
How are you looking at this procedure?
How are you looking at this procedure?
My safety with high quality with top technology is most important
Price is the most important part of this decision
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10
Would your lifestyle improve without glasses and contact lenses?
Would your lifestyle improve without glasses and contact lenses?
Yes
No
Test Score
Is the patient a candidate?
Is the patient a candidate?
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