Have you been told you have cataracts?
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Yes
No
Have you had any previous eye procedures (refractive surgery/LASIK)?
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Yes
No
Below are 4 zones of vision. Consider things in life you want to do without dependence on glasses, which group is most important to your lifestyle?
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Far
Intermediate
Near
Very near
All of the above
Are you suffering from any of these symptoms?
Trouble driving at night
Trouble reading fine print
See halos or glare at night
Colors appear faded
Multiple of the above
None of the above
What's Your Name?
First Name?
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Last Name
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What Email Can We Contact You At?
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Final Question: What Phone Number Can We Text Your Results To?
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