How old are you? *

Under 18

18-39

40-59

60+

Do you wear... *

Glasses

Contact lenses

Both

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

How important is the price of the vision correction procedure you’ll get? *

Price is not a concern of mine

Price is a concern, I'm on a budget

I'm willing to pay more for an excellent vision solution

What's Your Name?

First Name *

Last Name *

What Email Can We Contact You At? *

What Number Can We Text Your Results To?

(Final Question)

Phone *

*

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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