Brinton Vision Lasik Self Test - Brinton Vision Intake

I most often wear(Required)

glasses

contacts

readers

none of these

What is your age range?(Required)

15-44

45-55

56-106

Without my glasses I have trouble reading street signs(Required)

yes

no

Without my contacts I have trouble reading street signs(Required)

yes

no

Without my readers I have trouble reading street signs(Required)

yes

no

I have trouble seeing street signs(Required)

yes

no

I've been told I have astigmatism(Required)

yes

no

Without my glasses I have trouble reading my cell phone(Required)

yes

no

Without my contacts I have trouble reading my cell phone(Required)

yes

no

Without my readers I have trouble reading my cell phone(Required)

yes

no

I have trouble reading my cell phone(Required)

yes

no

How well do you see at night?(Required)

very well

ok, but could do better

quite poorly

When choosing your vision correction surgeon, which factors matter most to you?(Required)

experience of the surgeon

technology

safety

affordability

convenience

Would your life improve if you were less dependent on glasses and contacts?(Required)

absolutely!

maybe

not really

If you are a candidate, when would you like to have your procedure?(Required)

ASAP

next few months

>3 months out

During clinic hours, one of our knowledgable staff members will typically call you within 60 seconds to walk you through our process and schedule you for your consultation!

Name(Required)

First Last

Phone(Required)

Email(Required)