Have you had any previous eye procedures? (such as Refractive Surgery or LASIK)* This field is required.

Yes

No

Have you been diagnosed with cataracts by an eye doctor?* This field is required.

Yes

No

What do you currently use to correct your vision?* This field is required.

Reading Glasses only

Glasses

Contact Lenses

Nothing

How often do you currently rely on readers, glasses or contacts to correct your vision?* This field is required.

Frequently

Occsaionally

Rarely

Never

Coonsidering your personal and professional life, please check the one activity you do most often.* This field is required.

Computer Work

Reading

Driving

Physical Activity

Think about your DISTANCE vision: How important is it for you to perform tasks such as driving and playing golf without glasses after surgery?* This field is required.

Very interested in not wearing glasses for distance vision

It would be nice to not wear glasses for distance vision

I don't mind wearing reading glasses

Think about your NEAR vision: How important is it for you to perform tasks such as reading and texting without glasses after surgery?* This field is required.

Very interested in not wearing glasses for near vision

It would be nice to not wear glasses for near vision

I don't mind wearing reading glasses

How old are you? This field is required.

18-29

30-39

40-54

55+

How would you prefer to receive more information? This field is required.

Email

Phone

First Name* This field is required.

Last Name* This field is required.

Email* This field is required.

Phone* This field is required.

Message This field is required.

This field is required.

By completing this form, you are giving us permission to follow-up by phone, email or text.

Cataract Self-Test