Margolis LASIK Eye Self-Evaluation

1

Select your age group* This field is required

Under 18

19-39

40-59

60+

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2

What do you usually wear?* This field is required

Glasses

Contacts

Reading Glasses

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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

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4

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

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5

Can we get your name?* This field is required

First Name

Last Name

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6

What is your phone number?

Area Code

Phone Number

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7

What is your email?* This field is required

example@example.com

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8

The best way to contact you is?

Phone

Email

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9

Referrer

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10

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

YESNO

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11

Status

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