Pre-Appointment Survey – Groovy Glasses

First Name *

Last Name *

Email Address *

1. Which of the following daily activities do you struggle with due to your vision? (Select all that apply)

Using screens (work or personal)Driving (day or night)Outdoors or in bright lightReadingSports / exerciseHobbiesOtherNo — my current eyewear covers everything

2. What would you like to improve about your current glasses or contact lenses?

3. Would you like to explore any of the following options with our team? (Select all that apply)

Contact lensesPrescription swimming gogglesPrescription ski gogglesOther