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1. Do you have trouble seeing far away or close?
Select Your Answer*Far awayUp closeBothNeither
2. What do you currently use to correct your vision?
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3. What is your age?
Select Your Answer*18-3940-5555+
4. Do your glasses and contacts interfere with recreational or daily activities?
Select Your Answer*YesNo
5. What is your main concern with Laser Vision correction?
Select Your Answer*AffordabilitySafetyExperience of doctorOther
6. What are your primary reasons for wanting vision correction?
Select Your Answer*Save TimeSports/LeisureWorkDrivingReadingOther
7. Have you had a vision correction consultation before?
8. If you are a candidate, are you interested in a Free LASIK Consultation?
9. Where would you like your results & information sent to?
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