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Home
About Costello Eye
Our Physicians
Our Patients
In the News
Virtual Tour
Our Doctors
Services
Cataract Surgery
Dry Eye Center
Glaucoma Treatment & Surgery
Minimally Invasive Glaucoma Surgery (MIGS)
Laser Vision Correction
Eyelid Surgery
Pediatrics Center
Locations
Hamilton Office
Herkimer Office
New Hartford Office
Oneida Office
Rome Office
Oneonta Office
Cazenovia Office
Watertown Office
Griffiss Surgery Center
Patient Forms
Appointments
Insurance Information
New Patients
Patient Form
Patient History
Pay Your Bill
Contact
Careers
Tell Us About Your Visit
Go to...
Cataract Surgery
Dry Eye Center
Glaucoma Treatment & Surgery
Minimally Invasive Glaucoma Surgery (MIGS)
Laser Vision Correction
Eyelid Surgery
Pediatrics Center
Multifocal/Refractive Lens for Cataracts
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Cataract Surgery
Multifocal/Refractive Lens for Cataracts
Multifocal/Refractive Lens for Cataracts
Professional Media
2016-11-08T15:54:26-05:00
"
*
" indicates required fields
Full Name
*
Date
*
Month
Day
Year
What type of glasses do you presently wear?
*
None
Bi-Focal
Tri-Focal
Reading Only
Distance Only
Do you mind wearing glasses?
*
Yes
No
If you had the option NOT to wear glasses after Cataract surgery, would this be appealing to you?
*
Yes
No
Would you be content knowing you need glasses for some tasks?
*
Yes
No
Are you interested in seeing well AT DISTANCE without glasses after surgery?
*
Yes
No
Are you interested seeing well AT NEAR without glasses after surgery?
*
Yes
No
If you had to wear glasses after surgery for one activity, for which would you be most willing to wear glasses?
*
Reading fine print
Using the computer
Driving
Do you see halos or rings around lights when driving at night?
*
Yes
No
If you could become relatively independent from using glasses, but the compromise would be that you might see halos around lights at night, would you like that option?
*
Yes
No
How often do you do the following activities?
1 being rarely and 5 being often.
Reading
*
1
2
3
4
5
Close Detail Work
*
1
2
3
4
5
Computer
*
1
2
3
4
5
Watch TV
*
1
2
3
4
5
Outdoor Activities
*
1
2
3
4
5
Night Driving
*
1
2
3
4
5
How would you describe your personality?
*
Easy going
Detail & perfection oriented
Between the two
Which three zones would you prefer to see clearest without eyeglasses after surgery?
*
Stock Quotes, Phone book, Sewing, Map, Drug labels
Newprint, Computer, Makeup, Price tags, Menu
Television, Meals, Cooking, Clocks, Cleaning
Driving, Golf, Movies, Road Signs, Star gazing
Check three boxes
Name
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