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Reason for Contacting Us
—Please choose an option—Advanced Topography-Guided LASIKCataract or Refractive Lens SurgeryCorneal SurgeryCandidacy for vision correctionFinancingOther

By submitting this form, I give Furlong Vision Correction (FVC) consent to contact me at the phone number listed above, including by use of an automatic telephone dialing system, in regard to my request for information on FVC services and treatment information. By entering my email address, I consent to receive emails from FVC. I understand I can withdraw my consent at any time.

If you are asking a question about your vision, the following information will help us answer your inquiry.

Most recent prescription of your glasses (if known):

Do you have bifocals or reading glasses?

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