Question of 8

1

2

3

4

5

6

7

8

LASIK Utah Location

WELCOME TO
OUR LASIK SELF TEST

1. PLEASE SELECT YOUR AGE RANGE(Required)

UNDER 21

21-35

36-50

51-64

65+

2. PLEASE SELECT THE EYEWEAR YOU CURRENTLY USE(Required)

GLASSES

CONTACTS

GLASSES & CONTACTS

NONE

LASIK Utah Location

LASIK Utah Location

3. WITHOUT YOUR CORRECTIVE LENSES, YOU...(Required)

Struggle seeing far away

Struggle seeing close up

Struggle reading

Have overall blurry vision

4. CHECK ALL THAT APPLY(Required)

I have been diagnosed with an astigmatism

I have been diagnosed with cataracts

I have blurry vision

I strain to focus on objects

I experience eye muscle pain

I experience dry eye symptoms

LASIK Utah Location

LASIK Utah Location

5. I LEAD AN ACTIVE LIFESTYLE/PLAY SPORTS(Required)

YES

NO

6. WHAT IS YOUR NAME(Required)

YOUR FIRST NAME YOUR LAST NAME

LASIK Utah Location

LASIK Utah Location

7. PLEASE ENTER THE EMAIL WE CAN SEND YOUR RESULTS TO!(Required)

8. PLEASE PROVIDE THE BEST PHONE NUMBER FOR US TO REACH YOU AT(Required)

LASIK Utah Location

61786

Δ

Cleantalk Pixel

First Name*
Last Name*
Email*
Phone Number*
Which offer would you like to claim?

67364

Δ

BOOK YOUR VISIT

Book a Consultation

Please Select a Location(Required)

Name(Required)

First Last

Email(Required)

Phone(Required)

What Dates/Time are best for you?(Required)

Please include any other applicable details.

42251

Δ

Book Your Visit

Please Select a Location(Required)

Name(Required)

First Last

Email(Required)

Phone(Required)

What Dates/Times are best for you?(Required)

Please include any other applicable details.

80930

Δ

First Name*
Last Name*
Email*
Phone Number*
Which offer would you like to claim?

41437

Δ