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Forrest Beau Swann, MD, MS
Russell E. Swann, MD, FACS
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Name
*
First
Last
Phone
*
Email
*
What Is Your Age Group?
*
Under 18
18-40
40-65
66 and above
Have you noticed any changes or deterioration in your vision recently?
*
Yes
No
Without my glasses and/or contact lenses, I have trouble:
Reading and seeing up close
Driving and seeing things that are far away
What type of vision correction do you usually wear?
Contact Lenses
Reading Glasses
Bifocals, Trifocals, or Progressives
Describe your uncorrected vision. Check all that apply.
Blurry or Cloudy
Less Colorful, Colors Less Vibrant Than Before
Glare or Haloes Around Light Sources
Poor Night Vision
Double Vision in One Eye
Are you interested In seeing well up close (reading) without glasses?
*
Yes
No
What is your preferred method of contact?
Phone — A.M.
Phone — P.M.
Email
Text Message
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*
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Schedule A Consultation Today! 254.772.4499
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