Cataract Surgery Prescreening

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Name

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* 1. Name

Telephone Number (please include area code):

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* 2. Telephone Number (please include area code):

Email Address:

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* 3. Email Address:

Have you been diagnosed with cataracts in both eyes?

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* 4. Have you been diagnosed with cataracts in both eyes?

Do you have health insurance?

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* 5. Do you have health insurance?

Are you covered under Medicaid?

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* 6. Are you covered under Medicaid?

Are you a resident of South Carolina?

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* 7. Are you a resident of South Carolina?

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