Let’s get started! First, what is your age range?
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18-29
30-39
40-54
55+
Do you wear...
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Glasses
Contacts
Glasses & Contacts
Readers
Bifocals/Progressives
I don't wear anything (but I should!)
Without your corrective lenses, do you have...
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Trouble seeing far away
Trouble seeing up close
Overall blurry vision
Trouble with reading only
Are you ready to fix your bad vision?
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Yes!
Not sure
Thank you! What is your name?*
First Name
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Last Name
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What is your email address?
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[email protected]
What is a good phone number to reach you with?
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Please enter a valid phone number.
Were you referred to IVG by a friend, family member, or your doctor?
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Friend
Family Member
Doctor
None of these
How did you hear about Independent Vision Group?
Google Search
Facebook
Instagram
Radio
Word of Mouth
Other
Last question: If you qualify for vision correction, how soon would you like to improve your vision?
ASAP!
In the next few weeks
In the next few months
Sometime in the next year
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