• Format: +1 (000) 000-0000.
  • 1. How interested are you in seeing at a distance, driving, or playing golf without glasses after your cataract surgery?*
  • 2. Are you interested in seeing well up close (reading) without glasses after your cataract surgery?*
  • 3. If you had to wear glasses after your vision treatment for one of the following activities, which one would you most be willing to wear glasses for?*
  • 4. If you could have good vision for driving during the day without glasses, and good near vision without glasses in most situations, would you be able to tolerate some halos and glare around lights at night?*
  • 5. If you could have good distance vision day and night, and good vision for computer work, without glasses, would you be willing to wear glasses for reading fine print and small type?*
  • 6. In our daily lives there are different things we do that require us to SEE at different distances. We have grouped some of these vision activities into 5 lifestyle zones. Think about the things in life you want to do the most without depending on glasses after cataract surgery. Which group is the most important?*
  • 7. Consider your personality. Based on the options below how would you rank your personality?*

  • By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.

  • Oops! It looks like the phone number you input is invalid. Please input a valid phone number in order to submit.

  • Should be Empty: