Singh Vision Self-Test 1. How old are you? Select Age Under 18 19-39 40-59 60+ 2. Without my glasses and contacts... (check all that apply) Without my glasses and contacts I CAN see far. I CAN see near. I have a significant amount of astigmatism. 3. What do you usually wear? (check all that apply) What do you usually wear? Glasses Contacts None of Them 4. Do you have any of the following? (check all that apply) Any Following Rheumatoid Arthritis Multiple Sclerosis Lupus Cataracts Keratoconus Diabetic Retinopathy Prior eye surgery Prior eye injury Pregnant or nursing None of above 5. Would your lifestyle improve if you were to become less dependent on glasses and contact lenses? Rate Statement Yes No 6. Would you like to speak with our laser vision correction team? Rate Statement I'm ready to book my consultation! Yes, please call me to discuss my options. How Should We Contact You? This is how we will contact you to go over your results and schedule a complementary consultation. First Name Last Name Phone Number E-mail Can we text you? Can we text you? Yes No Get Results!
