Feedback Form

CONTACT INFO | Location Map | Office Hours | Driving Directions | Feedback Form

Please Fill Out Out Feedback / Seminar Form

First name:	Required
Last name:	Required
City	State: Zip:
E-Mail:	Required
Company Name:
Phone Number:

Best Time to Call? Mornings     Afternoon     Evenings

Gender: Male    Female

How long since your last eye exam?

Do you currently wear glasses?         Yes        No

Do you currently wear contacts?    Yes         No

If yes, do you wear hard or soft contact lenses?     Hard     Soft

Do you have a problem seeing at a distance?         Yes        No

Do you have a problem seeing up close?                Yes        No

Would you like us to contact you to schedule a free refractive surgery consultation? Yes     No

Would you like us to email you regarding upcoming vision seminars? Yes    No
Please contact me regarding your products and services:

Additional Questions or Comments:

1655 Bernardin Avenue, Suite 100
Columbia, SC 29204
803.256.4733

CONTACT INFO | Location Map | Office Hours | Driving Directions | Feedback Form