1. How old are you? +
2. You have difficulty seeing: Far, Near, Both? +
3.What type of vision correction do you wear? +
4. Would improving your vision change your life? +
5. What kind of work do you do? +
6. What hobbies and activities are important to you? +
7. If you prefer, our counselor could call, email, or mail information to you. (We would never distribute or sell address, phone or email lists.) When is the best time to call? +
8. General Info +
Name: +
Phone: +
E-Mail: +
Address: +
State: +
Zip: +
9. Have you been told that you are a candidate for cataract surgery? +
10. If you have been told that you are not a candidate for cataract surgery, would you like to hear about other possible options? +
11. Many patients tell us that deciding on vision correction surgery is a process. Where are you in the decision making process? +
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