What is your location? (City/State)
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What is your age?
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What Is Your Gender?
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Female
Male
What Eye Conditions are You Currently Experiencing?
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Are You Currently Willing and Able to Travel to Our Office in New Jersey to Improve Your Vision and Regain Your Life?
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Yes
No
How Would You Describe Your Current Vision?
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How Do Your Current Vision Problems Effect Your Life?
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How Urgent is This For You?
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1 - Not Very Urgent
2
3
4
5 - Very Urgent, Ready to Start Now!
What do You Feel is the Biggest Obstacle in Reaching This Goal and or Improving Your Vision?
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Who In Your Life Is Counting On You To Reach the Goal of Having Better Vision?
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What are you currently doing to improve your overall health and your vision?
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What sort of things have you tried in the past to improve your vision and how did they work?
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Would You Like a Consultation Call With Our Patient Care Manager?
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Yes
No