Neurolens Prescription Lenses Test

What symptoms are you currently experiencing?

Dizziness

Eye Strain

Headaches

Light Sensitivity

Neck Pain

Check all that apply.

What is the severity of these symptoms?

1 being Lowest and 5 being Highest

What measures are you currently taking to manage your symptoms?

Pain Medicine

Botox Injections

Chiropractor

Massage Therapy

Turning Off the Lights

Check all that apply

Does the object appear to move?

Yes

No

First Name*

Last Name*

Preferred Office Location*

Email*

Phone

Neurolens - Am I a Candidate