Cataract Self Evaluation

  1. What is your age group? under 18 19-3940-59 2. Were your first glasses more for reading or distance? Reading 3. Have you noticed any deterioration of your vision in the past 5 years?  Yes 4. Without my glasses and contacts: (check all that apply)       I have trouble reading and seeing things up closeI have trouble driving and seeing things that are far away     5. What do you usually wear? (check all that apply) Glasses Contacts 6. Describe your vision. (check all that apply) Blurry or cloudy Not as colorful or vibrant as it used to beHalos around lights and/or over-sensitivity to light Double or multiple images in one eye None of the above     7. Yes, I would like to schedule a FREE Exam or Consultation. The best time to call me is: ** 8am-12pm 4pm-7pm 8. Please provide us with your contact information: - - 9. Would you like to receive a Free Cataract and Premium IOL Info Kit?     Yes, Please mail my kit to the following address
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