Cataract Self-Test

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Do we have consent to text you?(Required)

What is your age range?(Required)

Under 50

50-60

Over 60

Have you ever been diagnosed with Cataracts?(Required)

Yes

No

Do you wear glasses or contacts to correct your vision?(Required)

No

Prescription Glasses

Reading Glasses

Contact Lenses

Are you having difficulty driving at night?(Required)

Yes

No

Do you have difficulty seeing street signs while driving?(Required)

Yes

No

Are nearby and distant objects not as clear as they used to be?(Required)

Yes

No

Do colors seem less bright?(Required)

Yes

No

Have you had an eye exam in the last year?(Required)

Yes

No

Phone

This field is for validation purposes and should be left unchanged.

Are You a Candidate for Cataract Surgery?