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Contact Us WIth Your Questions
 
NAME
ADDRESS
CITY
STATE
ZIP
HOME PHONE
E-MAIL ADDRESS
BIRTH DATE
EMPLOYER
ADDRESS
CITY
STATE
ZIP
WORK PHONE
Present Eye Doctor

  
How did you hear about us?
If television, which station?
If radio, which station?
If Internet Search, which keyword?
Do you wear contact lenses or glasses?
What type of contact lenses do you wear?
Please rate your satisfaction with 
glasses/contacts
Why are you considering Laser Vision Correction?
Are you prevented from doing any of these activities due to visual limitations?
  
On a scale of 1-5, please rate how important the following are to you (5 being the highest)
Safety of procedure
Expense
Financing Available
Experience of the doctor
Long term studies
Talking to former patients

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