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EYE CHECKUP - GET A NEW CLEAR VISION

YOUR EYE SIGHT IS OUR FOCUS.
Look at Life With a New Clear Vision!
Just answer the questions and we will get back to you soon with results & free tips.
www.krishnaeyecentre.com

* Required

Are you a computer user?
• YES
• NO
• SOMETIMES
Do you have eye pain, headache, dryness in the eye ?
If yes specify it on the following box.
Do you have burnig sensation in the eye?
• YES
• NO
• SOMETIMES
Are you irritated with blurred vision / cloudy vision?
• YES
• NO
• SOMETIMES
Are you a user of specacles / glasses or contact lenses?
• YES
• NO
• SOMETIMES
Do you want FREEDOM FORM GLASSES?
• YES
• NO
If you are a spectacle / contact lens user, write down your eye problem, power details etc?
Are you suffering from short sight?
• YES
• NO
Are you suffering from long sight?
• YES
• NO
If any of your family member suffering from any eye problems? Specially above age of 40?
• YES
• NO
If yes write down the eye details of your family member.
Do you have watering eye problem?
• YES
• NO
Do you want to go for an eye treatment in future?
• YES
• NO
Do you have any other eye problems? Write it here.
If you want to know more about eye care and its treatments, ask us.
You can also send your doubts through : http://goo.gl/55Ef2W
NAME *
EMAIL ID *
PHONE NUMBER
COUNTRY *

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