WELCOME TO YOUR
VISION SELF TEST
TO START
PLEASE TELL US HOW OLD YOU ARE
QUESTION 2:
HAVE YOU EVER BEEN TOLD YOU HAVE ASTIGMATISM?
QUESTION 3:
DO YOU HAVE TO WEAR GLASSES/CONTACTS FOR?
QUESTION 4:
HAVE YOU HAD ANY OF THE FOLLOWING PROCEDURES ON YOUR EYES (LASIK, PRK, RK, CATARACT SURGERY)?
QUESTION 5:
DO YOU SUFFER FROM MULTIPLE SCLEROSIS, LUPUS, KERATOCONUS OR DIABETIC RETINOPATHY?
QUESTION 6:
IF YOU WERE TO COME IN FOR A CONSULTATION, WHICH LOCATION WOULD WORK BEST FOR YOU?
QUESTION 7:
WHAT EMAIL SHOULD WE SEND THE RESULTS TO?
QUESTION 8:
WHAT IS YOUR FIRST NAME?
QUESTION 9:
WHAT IS YOUR LAST NAME
QUESTION 10 (THE FINAL ONE!):
WHAT PHONE NUMBER CAN WE USE TO CALL/TEXT YOU?