1
I wear...
Check all that apply
A
Glasses
B
Contacts
C
Glasses + Contacts
D
Neither
OK
2
How would you describe your current
vision situation?
Check all that apply
A
I can't see far away (nearsighted)
B
I can't see up close (farsighted)
C
I see things blurry at all distances (farsighted and/or astigmatism)
D
My vision is perfect, but I love taking quizzes!
OK
3
How many candles will be on your
next birthday cake?
A
Less than 18
B
18—45
C
46 or more
OK
4
What is your name?
OK
5
How often do you wear glasses or
contact lenses?
A
All the time
B
Only when reading or driving
C
I need them but rarely wear them
D
Never, I'm a superhero
OK
6
Have you ever had any of these eye
conditions or treatments?
Check all that apply
A
None, my eyes are healthy
B
Cataracts or glaucoma
C
Floaters
D
I've had a previous eye procedure
OK
7
How long have you been considering
laser vision correction?
A
Less than 2 weeks; I don't wait around
B
For the past fews months; had to do some research first
C
Been dreaming about it for years
OK
8
How do you feel about the possibility
of getting LASIK?
A
Excited, I can't wait!
B
Nervous but interested
C
Unsure, I need more information
D
Skeptical, not sure it's for me
OK
9
How much do you know about laser
vision correction?
A
I know a lot and have researched it extensively
B
I know the basics but have some questions
C
I've heard of it but don't know much
D
I'm not familiar with it at all
OK
10
What's most important to you when
partnering with a surgeon?
Chek all that apply
A
I want a surgeon with a lot of experience
B
I want a surgeon who invests in advanced technology
C
It's important that the office is close and has convenient appointment times
D
I'm looking for the best deal on eye surgery
E
My doctor needs to be a Taylor Swift fan
OK
11
What number can we text or call you
to discuss your results?
OK
12
What's your email address?
OK
13
How did you hear about us?
A
Online/Internet (e.g.,Google, Bing, SearchGPT)
B
Yelp
C
Social Media (e.g., TikTok, Instagram, Facebook, YouTube)
D
Reddit
E
Referral
F
Other
Submit