How Old Are You *

18-42

43-49

50-65

65+

What type of eyewear do you use most often? *

Readers/Bifocals

Contact Lenses

Prescription Glasses

None of the above

Readers/Bifocals

Do you use them to drive at night only? *

Yes

No

Contact Lenses

Do you wear readers on top of your contacts for the majority of your day? *

Yes

No

Prescription Glasses

Do your glasses help you see far away and up close? *

Yes

No

Have you been told that you have cataracts?

Yes

No

Which statement best describes your need for glasses or contacts?

To see objects and text up close

To see things far away

To see clearly both near and far

How soon are you looking to have your procedure? *

The next 3 months

The next 6 months

The next year

I’m gathering information

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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