Interested in cataract surgery?

Not sure if you’re a good candidate? Start here by filling out our patient survey to help you decide if cataract surgery might be a good option for you.

Self Evaluation             *indicates required field
First Name* Last Name*
Email* Phone*
What is your occupation?
What are your favorite hobbies/recreational activities?
Have you had prior eye surgery?
Yes
No
What is your age group:



When did you start wearing glasses:


Have you noticed any deterioration of your vision in the last 5 years?

Is your vision: (check all that apply)





Are you: (check all that apply)
Nearsighted (trouble seeing far away)
Farsighted (trouble seeing close up)
Astigmatism (double images)
Wear bifocals or over the counter reading glasses
Is it most important to you to have: (check all that apply)
Good distance vision (driving, golfing, watching TV)
Good intermediate vision (computer work)
Good close up vision (reading)
All the above
If you have cataract surgery, how important is it to you to be free of glasses and contacts afterwards?
Very important
Not important
Not sure
If you could enjoy good distance vision during the day for most activities without glasses, would you be able to tolerate some halos or glare at night?

 


Copyright © 2016 Valley Eye Associates. All rights reserved. | Privacy Policy
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Copyright © 2017 Valley Eye Associates. All rights reserved. | Privacy Policy
Refractive Marketing and Web Design by Eyemax