Cataract Patient Quality of Vision Online Form

This form is for cataract patients only. There is no need to fill out this form unless you are a cataract patient.

This short check list can assist us in determining which intra-ocular lens (IOL) best matches your visual needs. Advanced technology IOLs can provide good vision without glasses in many individuals.

If you do not wish to submit your form online you may download, print and fill out your forms and bring them with you to your appointment or fax them to 231-947-8864.

* required

E-Mail Address *

Name *

Date (mm/dd/yyyy) *

What activities are most important for you to perform without glasses?


Do you do a lot of night driving?

Do you do a lot of computer work?

Is your goal to see without glasses for:

How would you rate your personality?

What is or was (if retired) your occupation?

Do you have any specific visual needs or concerns?

Please type the word from the image in this field.

Traverse City
Local (231) 947-6246
Toll Free: (800) 968-6612

Mon - Wed, 8:00 AM - 5:00 PM
Thurs 8:00 AM - 6:30 PM
Fri 8:00 AM - 4:00 PM

929 Business Park Drive
Traverse City, MI 49686

Local (231) 487-2020
Toll Free: (866) 407-2020

Mon - Fri, 8:00 AM - 5:00 PM

2061 M-119
Petoskey, MI 49770

Sault Ste. Marie
Local (906) 635-9802
Toll Free: (800) 824-2711

Mon - Fri, 8:00 AM - 5:00 PM

511 Ashmun St.
Sault Ste. Marie, MI 49783