Have you been told you have cataracts? *

Yes

No

Have you had any previous eye procedures (refractive surgery/LASIK)? *

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? *

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: *

Last Name: *

What Email Can We Contact You At?

Email: *

What Number Can We Text Your Results To?

(Final Question)

Phone: *

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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