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David G. O’Day, M.D.
Dr. Tonya Castro, O.D.
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Self Evaluation
definitiveproductions
2016-05-12T18:57:37+00:00
Self Evaluation
1. What is your age group?
under 18
19-39
40-59
60+
Please select your Age
2. Without my glasses and contacts: (check all that apply)
I have trouble reading and seeing things up close
I have trouble driving and seeing things that are far away
I’ve been told that I have astigmatism
Please describe your vision.
3. What do you usually wear? (Check All that Apply)
Glasses
Contacts
Reading Glasses
Please select what you wear.
4. Do you have any of the following?
Rheumatoid Arthritis
Multiple Sclerosis
Lupus
Cataracts
Keratoconus
Diabetic Retinopathy
Prior Eye Surgery
Prior serious eye injury
I am currently pregnant
None of the above
Required
5. Yes, I would like to schedule a FREE Exam or Consultation. The best time to call me is: **
8am-12pm
12pm-4pm
4pm-7pm
Please select when you would like to be contacted for your consultation
6. Please provide us with your contact information:
First Name:
Required.
Last Name:
Required.
Email Address:
A Valid Email is Required.
Phone Number:
Area
Prefix
Suffix
–
–
7. Would you like to receive a Free LASIK Info Kit?
Yes, Please mail my kit to the following address
Street Address:
City:
Required.
State:
Required.
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District Of Columbia
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Ohio
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South Carolina
South Dakota
Tennessee
Texas
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Required.
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