How Old Are You? *

Under 18

18-39

40-59

60+

Do You Wear... *

Glasses

Contacts

Glasses & Contacts

Neither

Without Your Corrective Lenses, Do You Have... *

Trouble seeing far away

Trouble seeing up close

Overall blurry vision

Trouble with reading only

Have You Ever Been Told You Have Astigmatism? *

Yes

No

What's Your Name?

First Name *

Last Name *

What Email Can We Contact You At?

Email: *

What Number Can We Text Your Results To?

(Last Question)

Phone Number: *

By submitting this form, I authorize Dougherty Laser Vision to send text messages, possibly using automated technology, to the number provided. Message/data rates apply.

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