"*" indicates required fields Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.First Name*Last Name*Phone*Email* Consent I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (856) 997-2593 for assistance. You can reply STOP to unsubscribe at any time. Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.What is your age range?* Under 18 18-30 31-45 46-60 61+ Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.How would you describe your daily visual demands? (Select all that apply)* Select All Extensive computer/screen use Outdoor activities Precision work (e.g., crafting, engineering) Driving Reading Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.What are your primary concerns regarding your eye health? (Select up to 3)*Select between 1 and 3 choices. Digital Eye Strain Age-related vision changes Dry eyes Glaucoma Cataracts Macular degeneration Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Which eye care topics would you like to learn more about? (Select all that apply)* Select All Latest Eyewear (Frame) Technology Contact lens innovations Eye disease prevention Children's vision health Binocular Vision Dysfunction LASIK and refractive surgery Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Which of the following services or products would you be interested in learning more about? (Select all that apply)* Select All Myopia management for children Specialty contact lenses Binocular Vision Dysfunction Dry eye treatments Vision therapy Designer eyewear brands Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.How do you prefer to receive eye health information from our practice?* Select All Email Social media posts In-office brochures Video content Text message updates Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.How often do you typically update your eyewear?* Every year Every 2 years Every 3-5 years Only when necessary Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.How would you prefer to be reminded about upcoming appointments? (Select all that apply)* Select All Text Message Email Phone Call Postcard Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Which social media platforms do you use regularly? (Select all that apply)* Select All Facebook Instagram TikTok LinkedIn Twitter None of the Above Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.How likely are you to recommend our practice to friends or family? On a scale from 1 to 5:* 1 = Not at all likely to recommend 2 = Unlikely to recommend 3 = Neutral, neither likely nor unlikely to recommend 4 = Likely to recommend 5 = Extremely likely to recommend Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.What aspect of our practice would you highlight when recommending us to others?* Step 1 of 12 8%
