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1. How long have you been thinking about Refractive Surgery?
Less than 1 year
More than 1 year
Just heard about the procedure
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2. If you choose to have Refractive Surgery, how soon would you like to have it done?
Within the next month
Within the next year
Need more information before making any scheduling decisions
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3. Are you more likely to pay for your Refractive surgery with?
Cashiers Check/ Certified Check
VISA, Mastercard, American Express, Ect.
Payment Plan offered by Eye Center
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4. If offered a convienant payment plan, would you be interested in Refractive Surgery?
Yes
No
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5. Which day of the week is best for you to further discuss the LASIK procedure?
Monday
Tuesday
Wednesday
Thursday
Friday
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6. When, during the day, would you like to speak with Seltzer Laser Center about the LASIK procedure?
Morning
Afternoon
Evening
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7. Why do you want LASIK surgery?
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8. Who is your current eye doctor?
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