Margolis LASIK Eye Self-Evaluation

1

Select your age group* This field is required.

Under 18

19-39

40-59

60+

2

What do you usually wear?* This field is required.

Glasses

Contacts

Reading Glasses

3

Without my glasses and contacts* This field is required.

I have trouble reading and seeing things up close

I have trouble driving and seeing things that are far away

I've been told that I have astigmatism

4

Do you have any of the following?* This field is required.

5

Can we get your name?* This field is required.

First Name

Last Name

6

What is your phone number?

Area Code

Phone Number

7

What is your email?* This field is required.

example@example.com

8

The best way to contact you is?

Phone

Email

9

Referrer

10

I consent to receiving email communications.* This field is required.

YESNO

11

Status