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Please complete this free survey to find out if you are a candidate for Multi-focal Intra-Ocular Lenses (IOL's). This information will be needed when you come in to see one of our Ophthalmologists.
First Name
*
Last name
Email
Phone Number
*
Address
City
State
Zip code
Comments
Would you like to see objects up close without the use of glasses after your cataract surgery? (An example of this would be reading a book or newspaper.)
Yes
No
Would you like to be able to see objects at a distance without glasses after your cataract surgery?
Yes
No
Please mark the statement that best describes you in terms of night vision.
Night vision is extremely important to me and I require the best possible quality night vision.
I want to be able to drive comfortably at night but I would tolerate some slight imperfections.
Night vision is not particularly important to me.
If you had to wear glasses after surgery for one activity which activity below would you be most willing to use glasses?
Distance Vision
Mid-range Vision
Near Vision
If you could have good Distance Vision during the day without glasses and good Near Vision for reading without glasses but the compromise was that you might see some halos or rings around lights at night would you like that option?
Yes
No
If you could have good Distance Vision during the day and night without glasses and good Mid-range Vision without glasses but the compromise was that you might need glasses for reading the finest print at near would you like that option?
Yes
No
Surgery to reduce or eliminate your dependence upon glasses for Distance Mid-range and Near Vision may be partially covered by insurance if you have a cataract that is covered by insurance. Would you be interested in learning more about this options?
Yes
No
Maybe it depends on my insurance
On a scale from 1 to 10 1 being "Easy Going" and 10 being "Perfectionist" write in a number that best describes your personality.
*
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Our Surgery Center
Outpatient Surgery & Cosmetic Center
6550 Main Street Suite 2600
Zachary, LA 70791
Office 225.570.6357
Fax 225.570.2237
Zachary Location
2421 Church Street
Zachary, LA 70791
Office 225.654.1061
Fax 225.654.0791
Port Allen Location
4263 LA Hwy 1 South
Port Allen, LA 70767
Office 225.308.6311
Fax 225.490-4969
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