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General Information

Do you currently have sunglasses? *
Do you currently have computer glasses? *
Are you interested in contact lenses? *
Are you interested in LASIK? *
Symptom Frequency Rating
Please rate the following on a scale from 1–5, with 1 being never and 5 being always.
Headaches (of any severity, usually getting worse later in the day) *
Stiffness/pain in neck/shoulders (when working at a computer or reading) *
Discomfort with computer use *
Tired eyes (increasing throughout the day) *
Dry Eye Sensation (worse on computer or reading) *
Light Sensitivity (especially with stronger lights like headlights or fluorescents) *
Dizziness (experience motion sickness or vertigo) *
Eye Symptoms
Please select all that apply if your eyes experience the following:
Eye Symptoms
Additional Services
Would you like a complimentary anti-aging assessment? *
Are you interested in Wrinkle Treatments? *