See As Young As You Feel

Gordon-Binder-Weiss Vision Institute 1-800-950-6876

Are You a Candidate?

Take this survey to learn which vision correction treatment(s) may be best for your
specific needs.

Name(required)
E-mail(valid email required)
Phone
Are you over 40?
Yes No
Have you had good vision prior to turning 40?
Yes No
Describe your vision. Which of the following problems do you experience? Check all that apply
Seeing things far away Seeing things close up Reading a newspaper or book Driving at night
Have you previously undergone vision correction surgery?
Yes No
if yes, which one:
LASIK PRK RK Lens Implant Other
Have you been diagnosed with any of the following?
Cataracts Dry Eye Glaucoma Retinopathy Other None
Are you pregnant or nursing?
Yes No
Do you suffer from any chronic illness or disease?
Yes No
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