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Richard P. Stanek, M.D. Thomas J. Rice, M.D.James E. George, M.D.Phillip T. Sheridan, M.D.Aaron W. Tsai, M.D. Todd M. Watanabe, M.D. Scott A. Uttley, M.D.Susan J. Quick, M.D.Alla Kelly, M.D.Douglas P. Dworak, M.D., FACS Derek S. Horkey, M.D.Tracy W. Krick, M.D. Anne M. Poulsen, M.D. Alex L. Ringeisen, M.D. Erik S. Bachmeier, O.D.Trent N. Thielke, O.D. Alan E. Hein, O.D. Melissa M. Lopez, O.D.

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Contact Information

Name

Phone Number

E-mail Address

I would like to receive promotional offer emails from St. Paul Eye Clinic.

What is your age?

18-29

30-39

40-54

55+

My ability to see close (such as reading a book or using a mobile phone) is:

Good

Fair

Poor

My ability to see intermediate distances (cooking, computer, tablet) is:

Good

Fair

Poor

My ability to see far (ex: driving at night, viewing road signs, or watching TV) is:

Good

Fair

Poor

I experience halos and glare at night, especially when driving:

True

False

Would you like to see at a distance while driving or playing golf without glasses after your cataract surgery?

Yes

No

Would you like to see well up close without glasses after your cataract surgery?

Yes

No

How did you hear about St. Paul Eye Clinic?

I'm currently a St. Paul Eye Clinic patient.

Friend or Family Member

St. Paul Eye Clinic Employee

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