Do you have trouble seeing far away or close up? ---Far AwayClose UpBoth
Do you wear glasses or contacts? ---GlassesContactsReading Glasses
Have you tried monovision contacts? NoYes
What is your age? Under 2121-4041-6969+
What are you most interested in?
Have you had prior vision correction surgery (LASIK/PRK/RK)? NoYes
How interested are you in being without glasses and contacts? It is important to NOT to wear glasses or contacts while activeIt is not important to me; I don't mind wearing glasses
Are you interested in seeing well up close (reading) without glasses? It is very important to me NOT to wear reading glassesIt is not important to; I don't mind wearing reading glasses to see up close
Would your career or business activities improve if you were to become less dependent on glasses or contacts? YesNoMaybe
Do you use a computer? YesNo
How many hours per day?
Do you do a lot of driving at night? YesNo
Approximately when was your last eye examination? ---Less than a year1 to 3 yearsMore than 3 years
Choose the description that best describes your personality. ---extremely easygoingusually easygoingcan be a perfectionistextreme perfectionist
I authorize a Switch Eye Center representative to contact me to discuss the results of my Lasik Self-Test. I acknowledge that the information provided in this questionnaire will be used to send additional information about offers related to our services.
Yes, I authorize * authorize
Your Name (required) Your Phone (required) Your Email(required) Your Zip Code(required)
