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LASIK ConsultationCataract Surgery ConsultationEyelid Surgery ConsultationGeneral Eye Exam/Glasses/ContactsMedical Eye Exam (Known issue present)Dry Eye ConsultationOther

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If Yes, what is their first and last name?

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—Please choose an option—Already A PatientBillboardCollins Vision EmployeeCVPDoctor ReferralDrive ByEmailEventHospitalInsuranceLocal HeroesMagazineMailerNewspaper – NaplesNewspaper – Fort MyersNextdoor AppOnlineOther WebsitePatient ReferralPGA TournamentRadioRosen- Snead GroupShare the LoveSocial MediaTV Commercial

Preferred Office:

Fort MyersNaples

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Medical Insurance:

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