Cataracts Self Evaluation, Akron ohio Cataracts

1. What is your age group? under 18 19-39 40-59 60+ Please select your Age 2. Were your first glasses more for reading or distance? Reading Distance Please select your range 3. Have you noticed any deterioration of your vision in the past 5 years? Yes No Please select your range 4. Without my glasses and contacts: (check all that apply) I have trouble reading and seeing things up close I have trouble driving and seeing things that are far away I've been told that I have astigmatism Please describe your vision. 5. What do you usually wear? (check all that apply) Glasses Contacts Reading Glasses Bifocals/Trifocals Please select what you wear. 6. Describe your vision. (check all that apply) Blurry or cloudy Not as colorful or vibrant as it used to be Halos around lights and/or over-sensitivity to light Poor at night Double or multiple images in one eye None of the above Required 7. Yes, I would like to schedule a Consultation. The best time to call me is: 8am-12pm 12pm-4pm 4pm-7pm Please select when you would like to be contacted for your consultation 8. Please provide us with your contact information: First Name:Required. Last Name:Required. Email Address:A Valid Email is Required. Phone Number: Area Prefix Suffix -- 9. Would you like to receive a Free Cataract and Premium IOL Info Kit? Yes, Please mail my kit to the following address

Street Address:
City: Required. State: Required. Zip Code: Required.

330.923.5676