"
*
" indicates required fields
Step
1
of
6
- Step One
16%
I most often wear:
*
Glasses
Contacts
Readers
None of these
What is your age range?
*
15-44
45-55
56-106
I've been told I have astigmatism
*
Yes
No
Without my glasses I have trouble reading street signs
*
Yes
No
Without my contacts I have trouble reading street signs
*
Yes
No
Without my readers I have trouble reading street signs
*
Yes
No
I have trouble seeing street signs
*
Yes
No
How well do you see at night?
*
Very Well
Ok, but could do better
Quite Poorly
Without my glasses I have trouble reading my cell phone
*
Yes
No
Without my contacts I have trouble reading my cell phone
*
Yes
No
Without my readers I have trouble reading my cell phone
*
Yes
No
I have trouble reading my cell phone
*
Yes
No
When choosing your vision correction surgeon, which matters to you?
*
Affordability
Safety
Convenience
Experience of the surgeon
Technology
Would your life improve if you were less dependent on glasses and contacts?
*
Absolutely!
No way.
Maybe?
If you are a candidate, when would you like to have your procedure?
*
Next few weeks
Next few months
>3 months out
Contact Info
First Name
*
Last Name
*
Phone
*
Email
*
By submitting this form, you understand that you will receive a phone call, email, and text message from Tersigni Vision to help you get scheduled for your Tersigni Vision Ocular Analysis.
