First Name
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Last Name
*
What is the number you want us to text?
*
What is the best email for us to send you more info?
*
How long have you been dealing with these symptoms?
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Less than 6 months
6 months to 1 year
1 to 3 years
3+ years
Have you had cataract/lens surgery for BOTH eyes already?
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Yes, I've had both eyes done
I've only had one eye done
No, neither of my eyes have had surgery
Where are you located?
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Orange County, CA
Los Angeles/San Diego County
Inland Empire / Riverside / San Bernardino
Elsewhere in California
Out of State
Which symptoms are you currently experiencing? (check all that apply)
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Cloudy, blurry, or hazy vision
Unable to read phones, books, or computers without glasses
Increasing dependence on glasses
Difficulty driving after dark
Declining vision that affects my qualify of life
On a scale of 1 to 10, how urgent is fixing your vision for you right now?
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1 - 5 (not that urgent)
6-7 (I'm interested)
8-9 (I want this resolved quickly)
10 (I want this resolved ASAP)
Where did you find Dr. Tai? (check all that apply)
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Facebook
Instagram
YouTube
Referral
Google Search
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