Question 1/19
Do you wear corrective lenses?
Yes
No
Question 2/19
How do you rate your vision?
Poor - Can't see without corrective lenses
Medium - I should wear my corrective lenses at all times
Mild - I only need my corrective lenses when performing certain tasks
Question 3/19
What form of corrective lenses do you use? (click all that apply)
Select
Check All
Glasses
Hard Lenses
Daily contact Lenses
Weekly Lenses
Monthly Lenses
Question 4/19
What brand(s) of contact lenses have you used?
Select
Check All
Acuvue
Acuvue 2
Acuvue Advanced
Acuvue Oasys
Airoptics
Avaria
Bausch & Lomb
Biofinity
Biomedics
Biotrue Oneday Daily Lenses
Clearsight
Dailies Aqua Comfort
Dailies Total 1
Expressions
Focus
Focus Dailies
Frequency
Fresh Look
Hydrasoft
O2 Optix
Optima
Proclear
Proclear Multifocal
Pure Vision
Purevision 2 Lenses
Ultra Contact Lense
Vertex
Question 5/19
Are fashionable frames important for you when selecting your Eyeglasses?
Yes
No
Yes, but what looks best is what I get with price being a consideration
Question 6/19
Do you have prescription sunglasses?
Yes
No
No, but I am considering it
Question 7/19
Do you require bifocals?
Yes
No
Question 8/19
Which form of corrective Lenses do use them with?
Select
Check All
Eye Glasses
Contact Lenses
Question 9/19
Are you near or far sighted?
Near
Far
Question 10/19
Have you considered Corrective Surgery?
Yes
No
Question 11/19
How far along in the process are you?
Select
Check All
I want to get a consultation
Considering it, but I think it is too risky
Considering it, but I think it is too expensive
I am currently consulting with an eye care professional
I am scheduled to have surgery
Question 12/19
Do you have astigmatism?
Yes
No
Question 13/19
Do you have cataracts?
Yes
No
Question 14/19
Are you considering surgery for your cataracts?
Yes
No
Question 15/19
Have you been diagnosed with glaucoma?
Yes
No
Question 16/19
Do you currently have medical insurance?
Yes
No
Question 17/19
Please select your current medical provider
Select Options
Aetna
BCBS
Cigna
Humana
United Health
Medicare/Medicade
Chubb
Global Life
Met Life
Mutual Life of Omaha
NY Life
State Farm
Question 18/19
What is the name of your provider?
Question 19/19
lease select the current medical coverage you have
Select Options
HMO
PPO
Medicare
Medicaid
Last Question
Next Question