First Name: Last Name: Street Address:
City: State

Zip:

Email Address: Phone: Age:

Gender: Household income: Head of household:
Marital status: Race:  
 

Would you consider laser eye surgery?
Yes
No

Would you pay for a procedure if the cost was $1,300,for both eyes?
Yes
No

What is your perception of laser eye surgery?
Too Expensive
Too Risky
Safe and effective
Affordable
Convenient
Unsafe, the technology is to new
Would low interest financing encourage you to get a procedure?
Yes
No
Do you wear contacts or glasses?
Daily Contacts
Multi Day Contacts
Glasses
How would your rate your vision?
Poor, I can’t function without my corrective lenses
Moderate
Good, I need corrective lenses only part of the time, for driving or outdoor activity
Do you suffer from astigmatism?
Yes
No

Would you be willing to travel more than 1 hour to have a procedure done?
Yes
No

When would you consider getting laser eye surgery?
Within the next month
Within the next 3 months
Within the next 6 months
Within the next 9 months
Within the next year

What is the most important factor in making a decision for you to get laser eye surgery?
Price
Financing
Convenience
Quality & Reputation
There is no way I would get laser eye surgery
Guarantee

If you could finance your laser eye surgery now, would you get laser eye surgery sooner?
Yes, right away
Yes, in the next month
Yes, in the next 3-6 months
No, I need to budget it
No, it is a big decision I need to research
No

 


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