Dry Eyes Survey - CarlinVision

Dry eyes can stem from a variety of causes and conditions. We want to be sure you are getting the best possible treatment and results.

Your Name*

First Last

Your Email*

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Your Phone

Do you have any of the following symptoms?*

(Check all that apply)

Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease?*

When was your diagnosis?*

What is the approximate date that you were diagnosed with Dry Eye Disease or Ocular Surface Disease?

Have you had any of these procedures?*

Do you use any of the following?

(Check all that apply)

Have you ever been diagnosed with any of the following conditions?

(Check all that apply)

Have you ever had punctal plugs?*

Phone

This field is for validation purposes and should be left unchanged.